
ClassIELiXiia 

Book iki 

GopyiigMN?- 



COFOaGIlT DEPOSm 



I 



\ 



FRONTISPIECE 





The normal infant at eight months. 



PRACTICAL 
INFANT FEEDING 



By 

LEWIS WEBB HILL, M. D. 

Junior Assistant Physician to the Children's Hospital, Boston 
Assistant in Pediatrics, Harvard Medical School 



ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1922 



^"^ 






Copyright, 1922, by W. B. Saunders Company 



lADE IN U. S. 



PRESS OF 

W. S. SAUNDERS COMPANY 

PHIUAOEI-PHI A 



CLA659358 



To 

My Friend and Chief 

John Lovett Morse, A. M., M. D. 

A Truly Great Practical Clinician 

and Teacher 



PREFACE 



I HAVE tried to write a book on infant feeding which will 
be practical without being superficial, scientific without being 
tiresome. Its paramount purpose is to attempt to help the 
practitioner not only to treat but to understand feeding cases 
as they occur in his daily practice. It is absolutely essential, 
and not too much to ask, for the general practitioner, or anyone 
else who is feeding babies, to have a considerable knowledge of 
the chemistry of metabolism in normal and abnormal babies 
before they can feed them intelligently, and before they can be 
said to have a satisfactory working knowledge of infant feeding. 
This is what too many practitioners lack. They must know 
the processes that are going on in the digestive tract, and must 
understand what the difi'erent food elements do under various 
conditions, but so many conflicting views are held by various 
investigators in this country and abroad that it would be of 
little value in a text-book to attempt to give a review of the 
literature which forms the corner-stone of scientific infant feed- 
ing without setting any definite interpretation upon it. To my 
mind a text-book of infant feeding should consist of a clear pres- 
entation of what is generally believed on the subject, seen and 
interpreted through the eyes of the author, and largely supple- 
mented by his own practical experience. It should serve at the 
same time as a working guide for the general man and as a 
reference book for the pediatrist. 

I have tried in this book to effect a common-sense combina- 
tion of science and practice, to apply scientific principles to 
practice as much as possible, to go into a good deal of detail 
concerning certain scientific investigations which are of prac- 
tical importance, and to omit others which are not. It has not 
been my purpose to follow any one "school" of infant feeding, 



12 PREFACE 

but rather to amalgamate the best points taught in this country 
and abroad into what I hope is a homogeneous whole. 

It is desirable, of course, to make any subject as simple and 
as easily understandable as possible, and infant feeding need 
not be made complicated, but, on the other hand, any presenta- 
tion which does not explain underlying processes and the basis 
of symptoms is not enough for the thinking practitioner of 
today. As I heard an eminent Philadelphia pediatrist say not 
long ago, there is at present a tendency to try to make infant 
feeding so easy for the physician that there is a chance of for- 
getting whether or not the methods used may be suitable for the 
baby. 

The general standard of infant feeding in America has, 
however, improved greatly in the last ten years owing to the 
increased interest that general practitioners have taken in it, 
which is shown by the continually increasing numbers coming 
for instruction to the large post-graduate schools, such as the 
Harvard Graduate School of Medicine and the New York 
Post-Graduate School. 

To such men as this I respectfully offer this book, and 
sincerely hope that they may find it of value and interest. 

I wish especially to thank Dr. W. W. Howell for so kindly 
consenting to write the chapter on Premature Infants; Dr. R. 
W. Lovett and other members of the staff for permitting me to 
use several pictures and Roentgen-ray plates taken from their 
cases in the Children's Hospital; Mr. J. V. Footman for kindly 
making the prints and taking many pictures, and the publishers 
for their many courtesies. 

Lewis Webb Hill. 

483 Beacon Street, 

Boston, Mass., 

March, 1922. 



CONTENTS 



CHAPTER I 

PAGE 

The Physiology and Pathology of Digestion and Nutrition 17 

The Newborn Infant 17 

The Physiology of the Digestive Tract 22 

The Bacteriology of the Digestive Tract and the Relation of Bacteria 

to Food 28 

Fermentation and Putrefaction 32 

The Metabolism of the Food Elements 34 

Protein 34 

Fat 38 

Sugar 45 

Starch 56 

Salts 56 

The Vitamins 65 

Energy Requirements 69 

CHAPTER II 

The Stools in Infancy 75 

CHAPTER III 

Human Milk 90 

CHAPTER IV 

Breast Feeding 100 

The Normal Breast-fed Infant 104 

Difficulties Arising During Lactation Ill 

The Abnormal Breast-fed Infant 116 

CHAPTER V 

The Development of Modern Artificial Feeding 124 

Biedert 125 

Meigs 128 

Rotch 129 

Widerhofer 132 

Escherich 133 

Czerny and Keller 134 

Finkelstein 137 

CHAPTER VI 

Cow's Mn.K 145 

Chemistry 145 

Bacteriology 149 

The Production of Certified Milk 157 

Pasteurization and Sterilization 170 

The Essential Differences Between Cow's Milk and Human Milk . . 176 



14 CONTENTS 

CHAPTER VII 

PAGE 

The Modification of Milk 180 

Whole Milk Dilutions 181 

Top Milk Mixtures. 186 

Gravity Cream and Skimmed Milk Mixtures 188 

CHAPTER VIII 

Special Preparations Used in Infant Feeding 201 

CHAPTER IX 

The Artificial Feeding of the Normal Infant 228 

First Nutritive Period 231 

Second Nutritive Period 232 

Third Nutritive Period 233 

Mixed Diet During the Second Year 246 

CHAPTER X 

Digestive and Nutritional Disturbances in the Bottle Fed .... 252 

Underfeeding 256 

Acute Fat Indigestion 258 

Acute Sugar Indigestion 259 

Acute Protein Indigestion 263 

Acute Starch Indigestion 264 

Chronic Fat Indigestion (Type 1) 268 

Chronic Fat Indigestion (Type 2) 272 

Chronic Sugar Indigestion 274 

Marasmus 275 

General Suggestions for Difficult Feeding Cases 286 

CHAPTER XI 

Idiosyncrasy to Cow's Milk 289 

CHAPTER XII 

The Diarrheal Diseases 293 

Mechanical Diarrhea 295 

Fermentative Diarrhea 296 

Infectious Diarrhea 309 

Prophylaxis of Diarrheal Diseases 319 

CHAPTER XIII 

Chronic Intestinal Indigestion in Older Children 321 

CHAPTER XIV 

The Physiology, Care, and Feeding of Premature Infants 340 

By WILLIAM W. HOWELL, M. D. 



CONTENTS 15 

CHAPTER XV PAGE 

Constipation in Infancy 356 

CHAPTER XVI 
Habitual Loss of Appetite 360 

CHAPTER XVII 
Rickets 367 

CHAPTER XVIII 
Spasmophilia , 402 

CHAPTER XIX 
Scurvy 419 

CHAPTER XX 
The Treatment of Eczema in Infancy 438 

CHAPTER XXI 
Pyloric Stenosis and Spasm 452 

Index 467 



Practical Infant Feeding 



CHAPTER I 



THE PHYSIOLOGY AND PATHOLOGY OF DIGESTION 
AND OF NUTRITION 

THE NEWBORN INFANT 

Von Reuss^ (Vienna) gives the average weight of the normal 
full term infant as 7 lbs. 2 oz. for boys and 6 lbs. 9 J oz. for girls. 
Ramsey and Alley^ (Minnesota) in a series of 300 newborn 
babies found that the average weight was 7| lbs. for boys and 
7 lbs. 3 oz. for girls. In Curry's^ series of 521 cases (San Fran- 
cisco) the average was 7 lbs. 3 oz. for females and 7 lbs. 11 oz. 
for males. Hecker of Munich (quoted by Von Reuss) in a large 
series of cases observed the following weights: 

5 lbs. 8 oz. (2500-2999 gm.), 25.8 per cent, of cases 

6 lbs. 8 oz. (3000-3499 gm.), 44.4 

7 lbs. 11 oz. (3500-3999 gm.), 24.7 

8 lbs. 12 oz. (4000-4499 gm.), 4.6 

9 lbs. 15 oz. (4500-4999 gm.), 0.48 " 
11 lbs. (5000-5499 gm.), 0.02 " 

Every baby loses normally a certain amount of weight 
during the first few days of life. This loss, according to Talbot,^ 
is of two kinds: (1) mechanical, (2) physiologic. The mechan- 
ical loss is due to the passage of urine and meconium (70-90 gm.), 

1 Die Krankheiten des Neugeboren, Berlin, 1914. 

2 Amer. Jour. Dis. Chil., vol. 15, 1918. 

3 Quoted by Yerington, Jour. Amer. Med. Assoc, vol. 71, September 28, 
1918. 

< Amer. Jour. Dis. Chil., vol. 13, 1917. 

2 17 



l8 PRACTICAL INFANT FEEDING 

the loss from the removal of vernix caseosa and other secretions, 
and possibly sometimes the vomiting of allantoic fluid, which 
the baby may have swallowed before birth. The "physiologic*' 
loss of weight is that caused by actual oxidation of body sub- 
stance. For a few days, during the colostrum period, the baby 
is in a state of partial starvation, and the energy to supply his 
fuel needs has to come from oxidation of his body substance 
instead of from ingested food. The glycogen of the liver and 
tissues is first used, and when this is exhausted the body fat is 
burned. "Infants without a good layer of body fat should re- 
ceive food at the earliest possible moment" (Talbot). 

The colostriun period usually lasts about three days, and it 
is not until about the fourth day in most cases that the milk 
secretion is established. Colostrum is a concentrated food, but 
there is very little of it. According to the analyses of Camerer 
and Soldner, very early colostrum contains fat 4.08 per cent., 
lactose 4.09 per cent., protein 5.80 per cent., ash 0.48 per cent; 
according to those of Bailey and Murlin,^ fat 2.9 per cent., lactose 
7.1 per cent., protein 2.3 per cent. The amount of colostrum is 
usually estimated at about 20 c.c. on the first day, increasing 
somewhat on the second and third days. 

Loss of water from the body is also of considera"ble impor- 
tance, according to some authorities the most important factor 
in causing loss of weight. Birk and Edelstein^ found that the 
amount of water lost from the infant's body was 28.12 gm. per 
kilo for the first twelve hours, and 40.74 gm. and 53.6 gm. 
respectively for the next two twenty-four-hour periods. Von 
Reuss gave a considerable amount of water from the first day 
to a series of newborns, and noticed that there was much less 
loss of weight than in those babies to whom no water was given. 
The loss of weight continues for about three days, and on the 
third or fourth day the minimum is reached. The loss usually 
varies between 150 and 300 gm. (5-10 oz.), but occasionally 
may reach 400 to 500 gm. in babies who are apparently normal. 

1 Amer. Jour. Obstet., vol. 1, 1915. 

2 Monatschr. f. Kinderh.. vol. 60. 1910. 



I 



1>HYSI0L0GY AND PATHOLOGY OF DIGESTION AND NUTRITION 1 9 

If the breast milk is late in coming in, or if it is lacking in quality 
or quantity, the initial loss of weight may be considerably more. 
The loss is proportional to the absolute body weight, and is 
usually about 6 to 9 per cent, of it. There is less likely to be a 
large loss of weight if the baby is nursed on the first day, and at 
frequent intervals; babies nursed or fed artifically at four-hour 
intervals almost always lose more weight than those fed at 
2- or 2|-hour intervals. According to Benestad^ babies suffer a 
greater loss of weight, both relatively and absolutely, the greater 
the birth weight is. Most of the loss occurs during the first 
twenty-four hours, and according to various authors as much as 
125 gm. may be lost in this time. Most authorities are agreed 
that nothing can stop the initial loss of weight, but Schick^ in 
9 cases was able to prevent it by frequent forced feedings with 
a mixture of colostrum and breast milk. An excessive loss can 
be practically always prevented by proper feeding. According 
to Camerer the birth weight is regained by the eighth or tenth 
day, while according to Ramsey and Alley only about 25 per 
cent, of all cases regain the birth weight by the tenth day. 
Bergman,^ in a series of 1000 hospital cases, found that 11.4 
per cent, regained their birth weight by the tenth day, 21.7 
per cent, by the fourteenth day, and 24.1 per cent, had not 
regained it by the twenty-first day. All these babies were fed 
at four-hour intervals, however, and, moreover, were hospital 
cases. It is hardly fair, then, to accept these figures as a standard, 
and in most cases the average breast-fed baby in a private house, 
looked after carefully and fed at 2J- or 3-hour intervals will 
regain the birth weight by the fourteenth or fifteenth day. In 
the case of bottle-fed babies, however, the situation is far dif- 
ferent, and many normal babies who have had to be fed entirely 
on the bottle from the day of birth may fail to regain their 
birth weights before the end of the third or fourth week. 

Body Temperature. — ^At birth the body temperature is 

1 Jahrhb. f. Kinderh., vol. 80, 1914. 

2 Ztschr. f. Kinderh., vol. 13, 1916. 
« Ibid., March. 1916. 



20 PRACTICAL INFANT FEEDING 

relatively high (99,8°-100.8° F.), but during the first few hours 
of life a newborn baby loses a considerable amount of heat, 
and it is not unusual to record rectal temperatures of 95° F. in 
healthy full-term infants a few hours after birth. If the baby 
is kept warm the temperature soon comes up to normal, however. 
The first bath usually depresses the temperature from 1 to 1| 
degrees, and in the first week of life the daily variations are 
much greater than in older children (1° to 2° F.) (Von Reuss). 
The heat-regulating mechanism during the newborn period is 
very unstable, and newborn babies are likely to react differ- 
ently than older babies to infection. Severe infections, such as 
erysipelas, may in some cases cause only a slight rise of tem- 
perature, while in other cases the temperature may be very high 
from relatively slight causes. 

Transitory Fever of the Newborn. — Not a few normal 
infants show a rise of temperature to 101° or 102° F., most com- 
monly on the third, fourth, or fifth days. In many cases it is 
not accompanied by symptoms, while in others the baby may 
be restless and irritable, with mild toxic symptoms. Marked 
toxic symptoms are unusual, but may occur. The temperature 
usually lasts from twenty-four to forty-eight hours, and then 
rapidly subsides. It is difficult to estimate how frequently this 
transitory fever occurs, as it is undoubtedly often overlooked. 
CrandalP found at the Sloane Maternity Hospital in New 
York that it occurred in 135 of 500 consecutive newborns, a 
rather high percentage, while at the Nursery and Child's Hos- 
pital only 20 babies out of 200 showed it. Heimann^ found that 
if the baby was not put to the breast until twenty-four hours 
after delivery, from 2.3 to 4.2 per cent, had transitory fever, 
while if the nursing was begun 12 hours after delivery only 
0.6 to 1.3 per cent, showed it. Von Jaschke^ in 1000 newborns 
found only 31 with transitory fever. The etiology of the con- 
dition is not well understood. It has been usually called "inani- 

1 Arch. Ped., vol. 16, p. 174, 1899. 

2 Monatschr. f. Geburtsh. u. Gynakol., Bd. 51, 1920. 

3 Ztschr. f. Geburtsh. u. Gynakol., 78, 119, 1915. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 21 

tion" or "exsiccation" fever, and has been supposed to be due 
to the desiccation of the tissues during the first few days of the 
newborn period, when but little fluid has been taken. It has 
also been supposed to occur especially in babies who lose an 
excessive amount of weight, which is somewhat borne out by 
the fact that it is seen most commonly on the third to fifth day, 
when the weight has usually reached its lowest point. These 
views have, however, been recently disproved by Grulee and 
Bonar,^ who found that there was no regular relationship be- 
tween the occurrence of fever and the amount of fluid taken, or 
the weight loss. They believe that it is best explained by the 
absorption of some protein products, bacterial or otherwise, 
from the intestine, probably from putrefaction of the meconium, 
which is relatively high in protein and low in sugar. As soon as 
the breast milk comes in, and the high protein meconium is 
replaced by the high lactose breast milk, putrefaction stops, and 
the fever subsides. It is probable, however, that many factors 
are operative, and an excellent summary of them is given by 
Von Reuss^: 

"The replacement of meconium flora by milk flora in the 
intestine; the irritant effect of bacterial products of decom- 
position or toxins, and of nutritive ingredients on the intestinal 
cells, the presence of products of the breaking down of tissue 
such as occurs during the fiirst days of life; the deficiency of 
water, due partly to an inadequate external supply of fluid, and 
partly to internal causes, and the resulting concentration of 
tissue fluids and restriction of diuresis; and finally, the back- 
wardness of the mechanism of heat regulation." 

Diagnosis. — This is not ordinarily difficult, but it must be 
remembered that there are other causes of temperature in the 
first few days. Sepsis does not ordinarily have to be con- 
sidered, as it occurs very rarely before the fifth day. "Tran- 
sitory" fever practically always occurs before the fifth day. 
Furthermore, if sepsis is present, the focus can be found. Naso- 

1 Amer. Jour. Dis. Chil., vol. 22, No. 1, July, 1921. 

2 Diseases of the Newborn, London, 1920, p. 475. 



22 PRACTICAL INFANT FEEDING 

pharyngitis, otitis media, and pyelitis occur occasionally in 
newborns, and must be ruled out. I have recently seen a baby 
of three days with an otitis media which gave rise to a high 
temperature, and subsided as soon as the ear drmn was incised, 
and a considerable amount of bloody serum was evacuated. 
The ears should always, therefore, be examined in any newborn 
baby with an imexplained fever. With otitis media the baby 
is usually a good deal sicker than is the case with "transitory" 
fever. 

Pyelitis is very rare in the newborn, but has been reported. 
The diagnosis is made by an examination of a catheter specimen 
of the urine. 

Treatment. — One-half teaspoonful of castor oil should be 
given at once, and fluid and food forced. If the breast milk is 
late in coming in, as it very frequently is, a few ounces of breast 
milk should be secured from some other woman, and should be 
given In small, frequent feedings. If breast milk is not available, 
a weak cow^s milk modification is given, with a very low fat and 
protein and relatively high sugar. Water should be given fre- 
quently in as large amounts as possible between the feedings. 
The condition is not a dangerous one, and the fever practically 
always subsides in a day or two, without further symptoms. Its 
chief importance in most cases is that a good deal of alarm is 
unnecessarily experienced. In a few cases, however, toxic 
symptoms are marked, but usually subside after catharsis and 
free fluid and sugar intake. 

THE PHYSIOLOGY OF THE DIGESTIVE TRACT 
The Mouth. — ^Mouth digestion is relatively unimportant 
until the baby possesses ten or twelve teeth. Even then it is 
not as important as in adults, as babies ordinarily chew very 
little. The habit that many babies have of holding food in 
their mouths for some time before swallowing probably aids 
somewhat in the digestion of the starches, even if only a few 
teeth are present. The quantity of saliva in the first week of 
life is very small, but it has been shown to contain ptyalin. When 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 23 

the teeth begin to appear the secretion of saliva becomes more 
abundant. The weight of the saHvary glands at three months 
is double that at birth, and at a year is quadrupled.^ 

The stomach of the infant is placed more vertically than 
that of the adult, which accounts partly for the ease with which 
babies regurgitate. The pylorus lies slightly to the right of the 
midline between the umbilicus and the xiphoid. The average 
anatomic capacity of the stomach in newborn babies, according 
to Scammon and Doyle,^ is 25 c.c. The anatomic capacity, or 
size of the stomach, is however, not a good index of the physio- 
logic capacity, or amount of food that may be taken at one time, 
as a good part of it passes out through the pylorus before the 
last part has entered the stomach. The stomach increases 
rapidly in size during the first few days of life. According to 
Scammon and Doyle, the following average amounts of breast 
milk were taken at each feeding by a large series of normal 
breast-fed babies during the first ten days: 

Day. Amount taken at each feeding. 

1 7c.c. 

2 13 « 

3 27 « 

4 46 " 

5 57 « 

6 64 " 

7 68 « 

8 71 « 

9 76 " 

10 81 " 

The table below, showing the size of the stomach at different 
ages, is from Pfaundler and Schlossmann: 

Size of the Stomach at Various Ages 



1 month, 3 oz. 


4 months, 4 oz. 


7 months, 1\ oz. 


2 months, 3| " 


5 " 6 « 


8 « H « 


3 « 31 « 


6 " 6f « 


9 « 9 « 
1 year, 9f « 



* Gundobin, Die Besonderheiten des Kindesalters, Berlin, 1912. 
2 Amer. Jour. Dis. Chil., vol. 20, No. 6, 1920. 



24 PRACTICAL INFANT FEEDING 

Secretions of the Stomach, — The stomach secretes four sub- 
stances of importance: pepsin, rennin, hydrochloric acid, and a 
fat-splitting enzyme. In breast-fed babies free HCl is found 
about 2 hours after the meal in a concentration of about 0.10 
per cent. In bottle-fed babies it is found later, or not at all, on 
account of the greater powers of the cow's milk (casein) to com- 
bine with the acid. Inasmuch as free hydrochloric acid is a 
strong antiseptic agent, and undoubtedly destroys a good many 
of the bacteria which are introduced into the stomach, the 
stomach contents of a bottle-fed baby are less antiseptic than 
those of a breast-fed baby. This may be of considerable prac- 
tical importance in causing digestive disturbances by allowing 
the bacteria which have not been killed off to attack the food 
in the digestive tract. Stomach digestion proceeds somewhat 
as follows (Tobler): Soon after the milk enters the stomach it 
is coagulated by the rennin. The curd and whey are separated, 
and in the first part of the digestive period the liquid portion 
of the chyme is passed into the duodenum. Most of the casein 
and fat remain behind in the stomach and is slowly digested 
and liquefied by pepsin and hydrochloric acid digestion. The 
products of this (protein) digestion are albumoses and peptones. 
The fat also undergoes a certain amount of digestion by the 
action of the gastric lipose. Sugar is not acted upon, and most 
of it leaves the stomach in the whey. It is probable that even in 
babies with severe digestive or nutritional disturbance there is 
little or no deficiency of the gastric digestive ferments. There is 
very little absorption of either water or food material from the 
stomach. 

Motility and Emptying Time of the Stomach. — Peristalsis 
begins soon after taking food. The peristalsis of the stomach 
mixes the food thoroughly with the gastric juice, in the pyloric 
portion especially. At certain intervals the pyloric sphincter 
relaxes and the contraction wave squeezes some of the fluid into 
the duodenum (HowelP). According to Maynard Ladd,^ who 

* Text-Book of Physiology, Philadelphia, 1915. 
2 Amer. Jour. Dis. Chil., May, 1913, vol. 5. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 2$ 

has extensively studied gastric motility in infants by means of 
the Roentgen ray, "There is a curious lack of peristalsis to be 
seen in infants' stomachs as compared with adults. 

"The stomach empties itself of the greater part of its contents 
in from one to two and one-half hours. This time varies con- 
siderably, however, in different babies. After the greater part 
of the stomach contents has passed into the small intestine, a 
considerable residue remains, which is emptied very slowly, 
after remaining for from four to seven hours, in both bottle- 
and breast-fed babies." 

In most cases Ladd found that the stomach was nearly 
empty after two hours. A new feeding tends to stimulate per- 
istalsis and to push out ahead of it the residue of the previous 
feeding. 

There is a very great difference in the emptying time in dif- 
ferent babies, as Ladd found that with 3 infants of the same age 
on the same formula, 2 J, 3|, and 4| hours were required to empty 
their respective stomachs. The sort of food taken is, of course, 
important, and one infant in Ladd's series required on differ- 
ent occasions, with different formulas, 2^, 4i, 6, and 7| hours to 
completely empty his stomach. Sugar, either lactose or maltose, 
up to 7 per cent, has apparently no influence upon gastric 
motility. If the protein in the food is kept low even the fat 
fails to show any constant tendency to prolong the emptying 
time, and if the percentage of fat influences the motility at all 
the effect is not striking.^ Casein is the most important food 
element concerned in the emptying time; its effect in this respect 
depends considerably upon the form in which it is given. Pro- 
tein in high percentage without the addition of alkali retards 
the emptying time; if it is converted into a non-coagulable 
form by the addition of alkali, the stomach empties much more 
quickly. Sodium citrate does not influence the empt3dng time 
as much as do soda bicarbonate or lime-water. 

The duodenum secretes a not inconsiderable amount of 
alkaline juice, alkaline on account of its carbonate content. 
^ According to Tobler, fat delays the emptying time. 



26 PRACTICAL INFANT FEEDING 

This juice is not especially important in digestion (Burton- 
OpitzO. It contains invertin, which inverts cane-sugar, and 
also erepsin. Its chief importance is that it contains entero- 
kinase, a substance which has the power of activating the 
pancreatic juice so that it is more efficient in the digestion of 
protein. 

The Intestines. — ^Both the small and large intestines are 
relatively longer in the iafant than in the adult, which is prob- 
ably necessary on account of the relatively large amount of food 
taken by the infant. The small intestine secretes large quantities 
of alkaline juice, the succus entericus. It is light yellow in color, 
and its chief function is to break down carbohydrates, specially 
sugar, by the two sugar-splitting ferments which it contains, 
maltase and invertase, whose functions are to change disac- 
charids to monosaccharids. It also contains erepsin, which 
converts proteoses to polypeptids and amino-acids. 

The most import phases in the digestion of milk are carried 
on in the upper portion of the small intestine by the pancreatic 
juice and the succus entericus. The digestion of the various food 
elements are very delicately adjusted processes, which need a 
certain optimum reaction (not too acid or alkaline) in order to 
proceed satisfactorily. If there is an excessively acid or alkaline 
reaction in the small intestine where the digestion and absorption 
of food is taking place, these processes cannot proceed cor- 
rectly. The ordinary cause of excessively alkaline or acid 
reactions in the small intestine is the action of bacteria on foods 
there, and it can therefore be easily seen how important it is for 
the small intestine to be relatively free from bacteria. 

In the large intestine there is practically no digestion car- 
ried on, and probably little absorption, except of water. Nearly 
all the food that is going to be absorbed is absorbed before the 
ileocecal valve is reached. The large intestine is swarming with 
bacteria of many kinds, which live on the undigested or unab- 
sorbed food residue entering from the small intestine. If this 
residue is not too great in amount, excessive fermentation or 
^ Text-Book of Physiology. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 27 

putrefaction will not take place; if it is large in amount, one or 
the other of these processes becomes excessive, and diarrhea 
results. 

The liver in the infant is much larger in relation to the rest 
of the body than it is in the adult. In a newborn baby the liver 
is 4.33 per cent, of the body weight, in an adult, 2.85 per cent. 

The functions of the liver are to change starches, sugars, 
protein, and possibly fat into glycogen, to produce bile, and to 
neutralize and destroy poisons arising from the intestines. The 
liver is frequently enlarged in nutritional disorders, especially 
those arising from overfeeding with carbohydrate. 

The Bile. — Fresh bile is reddish-brown in color. Upon oxi- 
dation it changes to green, or upon reduction it may be color- 
less. Bile is what gives the color to the stools, and this color 
depends upon whether oxidation or reduction processes are 
taking place in the intestine. In the putrefaction that occurs 
when soap stools are produced the bile undergoes reduction 
and assumes a colorless form, so that the stools are nearly white. 
When sugar is fermenting, however, oxidation is taking place, 
and bilirubin is changed to biliverdin, which gives the character- 
istic green color to the stools. 

The chief function of bile is to aid in the digestion and 
absorption of fat. In the presence of bile the steapsin of the 
pancreatic juice is much more active in splitting fats than without 
it. Fat digestion is best in a nearly alkaline solution, and very 
poor in a strongly alkaline or especially in a strongly acid solution. 
Bile in a strongly acid solution is easily decomposed and rendered 
inefficient. It is able under the right conditions to dissolve large 
amounts of fatty acids, and also probably aids in absorption by 
emulsifying soaps. 

The Pancreas. — ^The juices of the pancreas are the most 
important and powerful of all the digestive juices. The pancreas 
has about the same significance in the infant as in the adult. It 
produces a strongly alkaline secretion in large amounts, which 
contains trypsin, amylopsin, and steapsin. These ferments 
digest protein, starch, and fat respectively, and are all present 



28 PRACTICAL INFANT FEEDING 

in the pancreas at birth. Pancreatic digestion cannot go on in 
a strongly acid medium. 

Summary. — From a practical point of view we are chiefly 
interested to know what part if any a lack of digestive ferments 
plays in the various digestive and nutritional disturbances of 
babies. The evidence here is conflicting, some investigators 
have found that certain ferments, particularly the fat-splitting 
ferment of the pancreas, are present in very small quantity or 
are lacking entirely in severe nutritional disorders, such as 
marasmus. It is probable, however, that this deficiency is not 
the cause but the result of the condition, and most investi- 
gators have found that in most cases of digestive disturbances in 
babies a deficiency of the digestive ferments plays little if any 
part. Thus the artificial digestants are of small practical value 
in the treatment of digestive disorders in infants. 

THE BACTERIOLOGY OF THE DIGESTIVE TRACT AND THE 
RELATION OF BACTERIA TO FOOD 

Importance. — The bacteriology of the gastro-intestinal tract 
is intimately concerned with problems of practical infant feeding, 
as there is normally always a slight bacterial decomposition of 
food going on in the lower portions of the bowel. If this decom- 
position becomes excessive, owing to poor digestion of food or 
overfeeding, large amounts of irritating substances are formed, 
which immediately get the baby into trouble, evidenced espe- 
cially by looseness of the bowel movements. 

The intestinal bacteria act on the host not directly, but 
through the intermediate agency of food, and its decomposition 
products. They are not ordinarily true parasites, but sapro- 
phytes; they live not on the tissue of the gastro-intestinal tract, 
but on the food within it. 

The intestinal contents at birth are sterile, and the first 
specimens of meconium passed usually fail to show bacteria. 
Infection takes place, in all probability, mostly through the 
mouth, but also probably partly through the anus, so that 
bacteria are ordinarily found in the meconium twenty-four 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 29 

hours after birth.^ "As a rule the proliferation of these first 
infecting organisms is limited, partly because the intestinal 
contents at this time are inadequate to support a large bac- 
terial population, partly because a majority of the bacteria are 
unable to accommodate themselves to gastro-intestinal con- 
ditions. 

"About the third day postpartum the alimentary canal of 
the infant becomes permeated with breast milk in place of the 
colostrum, and a marked change is discernible in the intestinal 
flora at this time. The heterogeneous, irregularly staining mi- 
crobes disappear to a remarkable degree, and coincidently large 
numbers of long, slender. Gram-staining bacilli appear. A 
majority of these belong to the group of Bacillus bifidus, and 
they usually persist in dominant numbers during the nursing 
period." 

The infecting bacteria come partly from the air, partly from 
the bath-water, or perhaps from the vagina of the mother. 
The initial bacterial flora is independent of the sort of food that 
there is in the intestine, but after the first two or three days is 
dependent upon the type of food that is present. According to 
Czerny and Keller it is not advisable to give sugar-water during 
the first day or two before the breast milk comes in, as is com- 
monly done, because fermentation might be started which 
would be injurious to the child. 

"If we feed the newborn in the first few days with foreign 
substances, we must remember that we may hinder or disturb 
the normal processes of invasion. It is best to give nothing but 
sterile water or water plus saccharin during the first twenty-four 
hours to a newborn baby."^ 

Bacteriology of the Stomach. — Many bacteria enter the 
stomach in the food of bottle-fed babies, but the gastric juice 
possesses strong antiseptic powers, and destroys a great many 
of them. The stomach, therefore, acts as a protection to the 
rest of the gastro-intestinal tract in this respect, and is on 

1 Kendall, Amer. Jour. Med. Sci., No. 2, vol. clvi, August 7, 1918. 
^ Czerny and Keller, Des Kindes Ernahrung, etc., 1906. 



3© PRACTICAL INFANT FEEDING 

account of its antiseptic power relatively free from bacteria in 
comparison with the lower portions of the digestive tract. From 
a practical point of view bacterial decomposition of the food in 
the stomach is not of much importance, except possibly in condi- 
tions of stasis, such as would exist with pyloric stenosis. 

Bacteriology of the Small Intestine. — The small intestine, 
especially in the upper portions, is also relatively free from bac- 
teria. The necessity of this is apparent, for if many bacteria 
were present and were continually attacking the food while 
digestion and absorption were taking place no proper digestion 
could occur. 

''The bacterial poverty of the upper part of the intestine, 
which, as long as physiologic conditions are maintained in the 
intestine, is reasonably constant, and guarantees a nonnal 
digestion process by the ferments alone without the interference 
of bacteria and bacterial decomposition products."^ 

The intestinal secretions (bile, pancreatic juice, succus enter- 
icus) have little if any bactericidal power, so the small intestine 
depends very largely upon the bactericidal power of the stomach 
to keep it from being overrun with bacteria. The epithelial cells 
of the small intestine, when functionally and anatomically intact, 
als6 probably possess a certain degree of antibacterial power^ 
and when these are injured in any way by inflammatory proc- 
esses, or their function is depressed by chemical agencies, a 
marked overgrowth of bacteria may take place. Roily and 
Leibermeister^ were able to increase the bacterial content of the 
small intestine by feeding large doses of soda bicarbonate or 
chlorid of iron. It has also been thought that the concentrated 
salt content of cow's milk may depress the antibacterial powers 
of the epithelial cells of the small intestine in such a way as to 
allow a greatly increased bacterial population to be present 
there, with a consequent decomposition of any food present. 
This has been given great importance by the Finkelstein school 

1 Tobler and Bessau, Allegemeine Pathologische Physiologic der Ernah- 
rung, etc., Wiesbaden, 1914. 

2 Cited by Tobler, p. 75. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 3 1 

especially. In the lower part of the ileum bacteria begin to 
increase in numbers, and conditions to approach those of the 
large intestine. 

Bacteriology of the Large Intestine. — The large intestine is 
swarming with bacteria of many varieties, maintained there by 
the food residue which comes from above. There are three 
probable reasons why the large intestine should be so rich in 
bacteria: 

The antiseptic action of the gastric juice does not reach so 
far down. 

Peristalsis is much slower than in the small intestine, and 
food, therefore, stays there a longer time. 

The epithelial cells of the large intestine possess no anti- 
bacterial power. 

Under normal conditions the amount of food present in the 
large intestine is not sufficient for enough decomposition to take 
place to cause trouble. Under abnormal conditions, when too 
large a residue of undigested food is present, the bacterial content 
may be enormously increased, and food decomposition, with its 
resulting irritating products, excessive. 

Blinds of Bacteria Present. — The flora of the breast-fed 
baby's intestine is remarkably uniform, and consists largely of 
the Bacillus bifidus, an organism living chiefly upon sugar, and 
forming lactic acid from it. The colon bacillus and the Bacillus 
lactis aerogenes are also numerous, and many other less impor- 
tant forms are present in smaller numbers. The fecal flora of 
the breast-fed baby is especially characterized by the fact that 
it is Gram-positive. In the bottle-fed baby conditions are not 
so uniform. *'The changes are, generally speaking, a substitu- 
tion of Gram-negatively staining bacteria of the colon type for 
a considerable proportion of the Gram-positively staining 
organisms so distinctive of the flora of the normal nursling, as 
well as the appearance of large bacilli (many of the spore- 
forming), cocci, and variable numbers of microbes that vary 
from time to time and from individual to individual."^ 
1 Kendall, Amer. Jour. Med. Sci., vol. clvi, No. 2, 1918. 



32 PRACTICAL INFANT FEEDING 

Dependence of the Type of Bacteria on the Food Supply. — 
Escherich was the first to show (1886) that the type of bacterial 
flora in the intestine is dependent upon the sort of food ingested 
and that changes in it can be produced at will by alterations in 
the food. As the food is changed those organisms which cannot 
adapt themselves to the new conditions die out, and others, of 
more adaptable type, take their place (Kendall). Escherich 
divided the intestinal bacteria into two broad groups, the putre- 
factive, which live upon protein food, and the fermentative, 
which live upon carbohydrate.^ If a food containing large 
amounts of protein and relatively small amounts of carbohy- 
drate is ingested, the putrefactive bacteria will flourish, and the 
fermentative tend to die out; if a high carbohydrate food is 
offered, the reverse is true. The reason why the flora of the 
breast-fed baby's intestine is so uniform is that his food is 
uniform; a high carbohydrate, low protein food, which encourages 
the growth of the characteristic bifidus flora (fermentative) and 
inhibits putrefaction. In the bottle-fed baby the conditions of 
food-supply are not so uniform, his food may be rich or poor in 
carbohydrate or protein, as the case may be, and his intestinal 
flora may change from time to time on account of the changes 
made in the food. In general, the feeding of cow's milk calls 
forth a putrefactive flora on account of the relatively large amount 
of casein it contains. These truths are of great practical impor- 
tance, and one uses them every day in his clinical feeding work. 

FERMENTATION AND PUTREFACTION 

In the breast-fed baby's large intestine conditions of fermen- 
tation normally obtain, owing to the high lactose content and 
relatively low casein content of breast milk, which maintains a 
fermentative flora and inhibits putrefaction. This gives rise to 
an acid reaction of the large intestine, as the products formed 
from fermentation of sugar are acid in character (largely lactic 
acid in the breast-fed baby). 

In the bottle-fed baby the question of whether fermentation 
* Some types may live upon either. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 33 

or putrefaction will predominate depends upon the character of 
the food; if large amounts of sugar are given, with little protein, 
fermentation results, with an acid large intestine; if large amounts 
of protein with little fermentable carbohydrate are given, putre- 
faction, with an alkaline reaction results, the end-products of 
protein putrefaction being alkaline in character. Within cer- 
tain limits these two processes can take place together, and 
ordinarily do so, but if one becomes markedly predominant, the 
other recedes. Under normal conditions a slight putrefaction 
exists in the lai^e intestine of a bottle-fed baby; if more protein 
and less carbohydrate is fed, this becomes increased. Normally, 
in the bottle fed, neither putrefaction nor fermentation should be 
too markedly predominant; if either process becomes so, trouble 
results due to the consequent overgrowth of bacteria and the 
irritating end-products formed. A sugar which is completely 
absorbed in the small intestine has little influence on fermenta- 
tive processes in the large intestine, but if it is absorbed with 
difliculty, and a considerable portion of it finds its way into the 
large intestine, it acts as a food for the ever-ready fermentative 
bacteria, and conditions of fermentation quickly result. As long 
as neither fermentation nor putrefaction is excessive, the reaction 
of the large intestine is either neutral, weakly alkaline, or weakly 
acid. If excessive fermentation or putrefaction results the re- 
action becomes too strong one way or the other, and diarrhea is 
caused by the irritant effect upon the intestinal mucosa of either 
the strongly acid or alkaline end-products. Under normal con- 
ditions the fermentation or putrefaction of food takes place in 
the large intestine only. Under abnormal conditions it may 
take place in the small bowel as well, these abnormal conditions 
being brought about usually by one of three agencies, or a 
combination of the three: 

1. The introduction of so many bacteria in spoiled milk that 
too many of them get through the stomach into the intestine in 
a viable condition. 

2. A depression of the antibacterial power of the epithelial 
cells of the small intestine from inflanmiation, from excessive 

3 



34 PRACTICAL INFANT FEEDING 

external temperature, debilitated condition of the baby^ or other 
agencies. 

3. The swallowing of infected mucus from rhinitis, bronchitis, 
or any upper respiratory infection. 

Types of Bacteria which Produce Fermentation or Putre- 
faction. — ^As fermenting organisms the following are the most 
important: the enterococcus, which is similar to the ordinary 
Streptococcus lacticus, the Bacillus bifidus and acidophilus, the 
coli aerogenes group, and the Bacillus aerogenes capsulatus, or 
"gas bacillus" (in pathologic cases especially). Some of these 
organisms cause lactic acid fermentation, some acetic or butyric 
acid fermentation. The colon, the butyric acid bacillus, and 
proteolytic bacteria are the most important putrefying organ- 
isms. The colon bacillus may attack either carbohydrate or 
protein, but if carbohydrate is present, grows upon this in 
preference. When the colon bacillus acts as a putrefier it 
attacks albumoses and peptones; it is probably not capable of 
attacking undigested protein. The proteolytic bacteria, on the 
other hand, have the power of breaking down undigested protein. 

Summary. — Most of our practical procedures in infant feed- 
ing, as regards intestinal conditions, are founded upon our knowl- 
edge of what causes fermentation, what putrefaction, the an- 
tagonism between the two, and a knowledge of how to dimin- 
ish one or the other by changing the type of food offered. A 
knowledge of the principles of intestinal bacteriology, the 
processes of fermentation and putrefaction, and the chemical 
changes involved is indispensable to a thorough understanding 
of infant feeding. These principles will be referred to many 
times in the course of the following pages. 

THE METABOLISM OF THE FOOD ELEMENTS 
1. The Metabolism of Protein. — Protein in the food has a 
threefold function (Rowland^): 

1. Part of it replaces tissue waste (desquamated cells, 
secretions, etc.). 

1 Amer. Jour. Dis. Chil., vol. 5, 1913. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 35 

2. Part of it is retained by the body to build up tissue. 

3. Part of it is burned and acts as a source of energy. 

For the infant the most important function of protein is the 
second — as a tissue builder. The infant retains a considerable 
amount of protein each day, often as much as 55 per cent, of 
that which has been absorbed. Sugar and fat (the fuel part of 
the diet) act as nitrogen sparers, and when they are given in 
sufficient amounts to furnish adequate fuel for the body only a 
small portion of the protein need be burned, and most of it is 
available for purposes of growth. This is illustrated by the 
metabolism experiment of Talbot and Hill,^ who found that 
increasing the amount of carbohydrate in the food markedly 
increased the retention of nitrogen. Thus, in a three-day 
metabolism period, their baby (J. P.) retained 2.06 gm. of 
nitrogen, corresponding to about 13 gm. of protein, when the 
carbohydrate intake was 216 grams. In the next three-day 
period the carbohydrate intake was 417 grams, and the retention 
of nitrogen was 3.16 grams, corresponding to about 20 grams of 
protein, which was nearly a third of the total amount of protein 
absorbed. 

Minimum Protein Needs. — Chittenden's well-known work has 
shown that the minimum protein needs for the adult, in order to 
keep the body in nitrogenous equilibrium and to replace cell 
*Vear and tear," are not high, and that it is possible to keep in 
nitrogenous equilibrium on about 0.73 gm. of protein per kilo- 
gram of body weight, provided adequate amounts of carbohy- 
drate and of fat are given. One would naturally expect that the 
figures would be considerably higher for babies and children 
on account of the relatively large amounts of protein needed for 
growth. Such is indeed the case, although in babies and children 
it has not been possible to carry out any such extensive or ac- 
curate investigations as those of Chittenden for adults. About 
the only standard we have to go by is breast milk. We know 
that this is relatively low in protein, that most of its fuel value 
is furnished by the fat and sugar, that little of the protein in 
1 Amer. Jour. Dis. Chil., vol. 8, 1914. 



36 PRACTICAL INFANT FEEDING 

breast milk is used for fuel, and that probably the amount which 
it contains represents the optimum amount to furnish nitrogen 
for growth. It is true that the biologic value of the protein of 
breast milk is somewhat greater than that of cow's milk pro- 
tein on account of its constitution, being made up as it is of 
the most suitable amino-acids for cell growth. This difference 
is not great enough, however, to invalidate the use of the pro- 
tein content of breast milk as a rough standard of comparison 
in artificial feeding. 

A breast-fed baby of 8 kilograms (17| lbs.) would take as a 
maximum not over 1000 c.c. of breast milk per day, containing 
about 12.5 grams of protein. This would furnish about 1.5 
grams of protein per kilogram of body weight. Inasmuch as 
about 20 per cent, of the nitrogen of human milk is unavailable 
for use, being in the form of extractives, as Rowland^ has pointed 
out, this would mean only about 1.20 grams of protein per 
kilogram of body weight. The breast-fed baby can and does 
thrive then on this amount. 

The usual amount that has been considered necessary in 
feeding with cow's milk is 1.5 gm. per kilogram. According to 
Hoobler,^ if 7 per cent, of the total calories are given as protein 
calories, the nitrogen needs will be amply provided for. Or, as 
others have said, the protein contained in 1.5 ounces of whole 
milk per pound of body weight per day meets the protein re- 
quirement. As a matter of fact, there is little danger of going 
below the minimum protein need in any of the ordinary milk 
modifications used, and almost always considerably more than 
this is given, especially if whole milk dilutions are used, under 
which conditions the baby uses a considerable part of the protein 
intake for fuel. 

In practical infant feeding, therefore, it is rarely necessary 
to calculate the protein requirements if at all reasonable con- 
centrations of milk are employed. If condensed milk or certain 
of the proprietary foods are used, however, the protein intake is 
often too low. 

1 Loc. cit. 2 Amer. Jour. Dis. Chil., vol. 10, No. 3, 1915. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 37 

The Digestion and Absorption of Protein. — The casein of 
cow's milk is coagulated in the stomach into large tough curds; 
the whey protein does not undergo coagulation. The casein of 
human milk is precipitated in soft flocculent curds. The 
mechanism of the coagulation of casein is somewhat as follows: 
The gastric enzyme, rennin, acts upon the casein and converts 
it to paracasein. This paracasein then reacts with the calcium 
salts of the milk, and forms an insoluble curd consisting of a 
combination of paracasein and calcium (calcium caseinate). The 
fat of the milk is mechanically combined with the casein curd, 
probably by becoming entangled in its meshes. 

A considerable portion of the calcium caseinate is broken 
down in the stomach by the pepsin, and hydrochloric acid into 
albumoses and peptones. The digestion is then carried on further 
by the trypsin of the pancreatic juice and the erepsin of the 
succus entericus, trypsin digestion being the more important. 
These ferments break down the albumoses and peptones into 
polypeptids and finally amino-acids, which are absorbed free or 
in combination with various salts. Trypsin is capable of attack- 
ing protein before it has been changed to albumoses and peptones, 
and probably normally does so, as some of the milk leaves the 
stomach so quickly after ingestion that there has been no time 
for digestion to take place. 

The absorption of protein in health is good, from 90 to 95 
per cent, of the intake being absorbed, and is equally good in 
both bottle- and breast-fed babies. The absorption is likewise 
good in most nutritional disturbances unless there is an asso- 
ciated diarrhea, under which conditions it is always poor. 

Action of Protein in the Intestine. — ^The unabsorbed residue 
of protein food is alkaline in reaction, partly owing to the 
ammonia which may be formed, partly due to the large amount 
of calcium always ingested when high concentration of milk 
(with a high protein content) are fed, partly due to the fact that 
high protein feeding causes an increased pancreatic and intes- 
tinal secretion, both of which are alkaline in character. If small 
amounts of protein are ingested, together with large amounts of 



38 PRACTICAL INFANT FEEDING 

carbohydrate, there will be little if any putrefaction in the 
intestine owing to the fact that in general the intestinal bacteria 
attack sugar in preference to protein, when plenty of sugar is 
offered, and the fermentation thus taking place inhibits putre- 
faction. If large amounts of protein and small amounts of car- 
bohydrate are taken, the unabsorbed carbohydrate residue is 
small, and is insufficient to support a fermentative flora, so the 
proteolytic forms gain the upper hand, and the facultative forms, 
which can live upon either carbohydrate or protein, attack the 
protein, as there is no carbohydrate for them. The reaction of 
the intestinal contents when putrefaction is in the ascendancy is 
always alkaliue (as in the normal bottle-fed baby). This is 
normal provided it is not excessive; if it becomes excessive the 
smooth, slightly foul, yellow, normal "high protein" stools 
change to the loose, brown, more foul stools of abnormal protein 
putrefaction. 

2. The Metabolism of Fat. — Fat forms an important part of 
the food as regards calories, for 1 gram of fat furnishes 9.3 
calories as against the 4.1 calories furnished by an equal amount 
of carbohydrate or of protein. It is not, however, so necessary 
to life as carbohydrate, provided an adequate caloric intake is 
furnished by the other food elements, and a baby may be 
fed over a considerable period on a fat-free diet without 
injury,^ 

Fat as it exists in milk is in the form of neutral fat, a com- 
bination of glycerin and higher fatty acids. During the process 
of digestion the neutral fat is split into these two component 
parts. The stomach contains a ferment capable of splitting a 
certain portion of the fat, but this is probably of relatively little 
importance, and most of the fat digestion takes place in the 
upper portion of the small intestine, where the steapsin of the 
pancreatic juice splits it into glycerin and fatty acids. The 

^ Recent work has shown that prolonged feeding on a diet containing an 
inadequate amount of fat may bring about arrested growth, and various 
disturbances of nutrition, probably on account of the lack of the fat-soluble 
vitamin. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 39 

fatty acids combine with alkaline carbonates in the intestine 
(Ca, Mg, Na, K) to form soaps, which are emulsified and made 
soluble by a combination with the bile and then absorbed. The 
soaps during their passage through the intestinal wall are 
res)mthesized into neutral fat by ferments contained probably 
in the epithelial cells. The soaps formed are largely of the higher 
fatty acids (palmitic, stearic, oleic) ; the calcium soaps, especially 
that of palmitic acid, are relatively insoluble and are absorbed 
with difficulty. The sodium and potassium soaps are more 
easily absorbed. According to Bosworth, Bowditch, and Giblin^ 
100 gm. of butter fat when saponified yields 3S per cent, of 
palmitic acid, the calcium soaps of which are relatively insoluble. 
When the fat of human milk is saponified less palmitic and more 
oleic acid is produced, the soaps of oleic acid being more soluble 
than those of palmitic. In general, the lower the melting-point 
of a fat or fatty acid, the easier is its absorption. The melting- 
point of palmitic acid is high (62 degrees), that of oleic acid low 
(14 degrees). 

The importance of the bile for fat absorption is shown by 
Parker's case, a girl with a biliary fistula of such a nature that 
no bile whatever reached the intestine.^ In a three-day metab- 
olism period he found that only 64 per cent, of the fat intake was 
split and only 55 per cent, was absorbed. The absorbed fat 
enters the lacteals, is carried to the circulation largely by way 
of the thoracic duct, and is used by the body as fuel, the end- 
products being carbon dioxid and water, or is deposited in various 
organs and tissues. 

Percentage of Fat Intake Absorbed. — Fat absorption in health 
is remarkably good both in breast- and in bottle-fed babies. 
The most complete investigation of the subject is by Holt, 
Courtney, and Fales,^ and the following data are taken from 
their publications: 

Normal breast-fed infants were found to absorb an average 

1 Amer. Jour. Dis. ChiL, vol. 15, No. 6, 1918. 

2 Ibid., vol. 5, 1913. 

3 Ibid., vol. 17, April and June; vol. 18, August and September, 1919. 



40 PRACTICAL INFANT FEEDING 

of 95 per cent, of the fat ingested. The figures of other authors 
vary from 92 to 99 per cent. In 3 breast-fed infants who were 
not doing well (2 with diarrhea) the fat absorption was 79, 62, 
and 52 per cent. 

Constipated bottle-fed babies were found to absorb an 
average of 90 per cent.; bottle babies with normal stools, 91 
per cent. If the stools were slightly softer than normal the 
absorption sank to 88 per cent. ; if they were loose, to 84 per cent., 
and if there was an actual diarrhea, the absorption was only 
79 per cent. 

According to all writers the lowest fat absorption occurs in 
diarrhea, and in severe cases may fall as low as 50 per cent, of 
the intake. The cause of the diarrhea need not be an excessive 
fat intake; apparently the low absorption is mostly due to the 
fact that the increased peristalsis hurries fat through the bowel 
so quickly that it cannot be absorbed, and partly to the changed 
chemical conditions that are present in the intestine with any 
diarrhea, whatever its cause. 

In the stools of any bottle-fed baby there is a considerable 
amount of insoluble soap, but this does not necessarily mean a 
poor fat absorption. With typical, light colored, dry, alkaline 
soap stools there is probably always a poor fat absorption, 
although some of the earlier writers found it normal. This was 
probably due to faulty methods of analysis. 

Bahrdt,^ who in 1910 made an exhaustive study of soap 
stools, found that the fat absorption varied between 82 and 86 
per cent, when typical soap stools were passed, which is a con- 
siderable difference from the normal average absorption. The 
chemistry of soap stools has been for years a subject of pains- 
taking study, but the exact processes concerned in their formation 
are as yet not well understood. Dry, whitish-gray, crumbly 
stools occur in the condition, which was called by Czerny 
"Milchnahrschaden," by Finkelstein "Bilanzstorung," and has 
been usually called in America chronic fat indigestion (see 
Chapter XI). 

1 Jahrb. f. Kinderh., 1910, Ixxi, 249. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 4 1 

Soap stools, according to Howland/ are formed when three 
conditions are present in the food: 

1. A moderate or a large amount of fat. 

2. A large amount of calcium and of casein. 

3. A lack of carbohydrate. 

On account of the large amount of casein and of calcium 
present in the food and the lack of fermentable carbohydrate 
the intestine becomes alkaline and peristalsis is slowed. This 
favors the formation of insoluble calcium soaps, in just what 
way is not certain. The fat absorption becomes poor, as so 
much of the fat is changed into insoluble calcium soaps, which 
are absorbed with relative difficulty. There is also a very poor 
retention of calcium and magnesium, with a consequent relative 
acidosis and an ammoniacal urine. The subsequent impairment 
of nutrition, which may be severe if the process is unchecked, 
cannot be due to the loss of fat calories alone, as in most cases 
not more than 30 or 40 calories a day would be lost in this way 
over the normal amount. Fat must have something to do with 
the condition, however, as it is not seen except when there is a 
considerable amount of fat in the diet, and a baby may be fed 
on a fat-free food, no matter how rich in calcium or casein it 
may be, or how poor in carbohydrate, without developing this 
typical nutritional picture. 

It is probable that the poor calcium retention is the most 
important single factor in producing the nutritional change 
which occurs, which is borne out by the fact that a good many 
of these babies develop rickets or spasmophilia, both conditions 
which are dependent upon poor calcium retention. The reason 
why the calcium retention should be poor is obscure, and cannot 
be accounted for entirely by the combination of calcium with 
unabsorbed fatty acids to form soaps, as Bahrdt^ has shown that 
there is not enough fatty acid present to bind all the calciimi 
that is excreted. 

According to many authorities there is a primary deficient 

1 Amer. Jour. Dis. ChiL, vol. 5, 1913. 

2 Loc. cit. 



42 PRACTICAL INFANT FEEDING 

calcium absorption dependent upon increased excretion, and the 
formation of soap stools is a secondary matter. 

Whatever the exact cause of soap stools may be, it seems to 
us that the process which brings them about is simply an exag- 
geration of that which occurs in the intestine of any normal 
baby fed on dilutions of cow's milk rich in casein and calcium 
and relatively low in carbohydrate. The normal stool of a 
bottle-fed baby is like a soap stool in a good many ways, it is 
alkaline, formed, slightly foul in odor, and contains a good deal 
of calcium soap. If the relations of the elements in the food are 
changed still further, so that the food is still lower in carbohy- 
drate and higher in calcium and casein or fat, typical soap stools 
result, which differ essentially from the normal stools of a 
bottle-fed baby only in that they are very light colored, more 
constipated, and contain more calcium. The process is in no 
sense different in kind from that which produces the characteristic 
bottle-baby stools — ^it is different only in degree, and all grada- 
tions may occur between the yellowish-brown, formed normal 
stool, to the more constipated, larger, grayish-white soap stool. 
For this reason it is not always easy to tell what is a pathologic 
soap stool and what is not. The color, the large amount of fat 
seen under the microscope, and the condition of the baby are 
the most important criteria. 

Fat Partition in the Stools. — Fat in the stools exists as neutral 
fat which has not been acted upon at all by the digestive 
juices, as fatty acid, representing fat which has been split, 
but not saponified, and as soap, which has been both split and 
saponified. 

The total fat normally forms a large proportion of the dried 
weight of the stool. According to Holt, Courtney, and Fales,^ 
in normal stools from breast-fed infants 42 per cent, of the dried 
weight consists of fat. Stools which were green and contained 
a good deal of mucus were found to contain only 23 per cent, of 
fat, on account of the relatively large amount of other material 
present (bacteria, mucus, etc.). In normal bottle-fed babies 

1 Loc. cit. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 43 

who were taking ordinary mixtures of cow's milk 36 per cent, 
of the dried stool consisted of fat, and in older children fed on a 
mixed diet the figure was 18 per cent. These lower figures for 
artificially fed babies and for older children are to be expected, 
as in bottle-fed babies there is a comparatively large residue of 
unabsorbed casein and calcium, and in children fed on a mixed 
diet, of cellulose. Most of the fat present is in the form of soap, 
especially if the stools are alkaline in reaction. If the stools 
are strongly acid there is a decrease in the percentage of soap 
and an increase in the fatty acid. Fat in an alkaline intestine 
tends to form soap; in an acid intestine, fatty acid; soaps tend 
to produce constipation; fatty acids, diarrhea. Thus it is that 
the effect of fat upon the intestine and upon the metabolic 
processes depends largely upon the reaction of the intestine, 
which, in its turn, depends upon the relative proportions of 
sugar and protein in the diet. When the sugar and protein are 
weU balanced, and there is neither a strong alkaline or strong 
acid reaction in the intestine, large amounts of fat when ingested 
are more likely to produce acidity than alkalinity, on account of 
the fatty acids formed during digestion of the fat. It is also 
probable that bacteria attack undigested fat and break it down 
into fatty acid. The fatty acids which are formed from the 
breaking down of fat are higher members of the fatty acid 
group (oleic, stearic, and palmitic), are solid at ordinary tem- 
peratures (with the exception of oleic), non- volatile, and not 
particularly irritating to the intestinal mucosa. The lower 
members of the fatty acid group (acetic, butyric) are liquid, 
volatile, and extremely irritating to the intestine. It is theo- 
retically possible that the lower members could be produced 
from the higher by still further splitting, and it is probable that 
this occurs to a certain extent when fermentative bacteria are 
active. It is probable, however, that this splitting does not 
take place to any great extent, and that when butyric and 
acetic acids are found in the stools they come from the sugar 
rather than from the fat. A diarrhea from sugar is likely, there- 
fore, to be more irritating and profuse than one from fat, on 



44 



PRACTICAL INFANT FEEDING 



account of the greater irritating effect of the lower fatty acids 
arising from sugar decompostiton. 

Fat splitting is almost always good except when diarrhea 
occurs, or excessively large amounts of fat are fed, therefore only 
a small portion of the stool fat ordinarily consists of neutral 
(unsplit) fat. If a large amount of neutral fat is found in the 
stools microscopically a severe fat incapacity is indicated. In 
most cases of "fat indigestion" the trouble is not an "indigestion" 
at all, but is a failure of absorption of the fat which has been 
digested. 

Table I, from Holt/ shows the distribution of the fat in the 

stools of normal and abnormal bottle-fed babies, and of children 

on a mixed diet; Table II compares normal breast and bottle 

babies. 

TABLE I 





Total fat 

per cent, of 

dried weight 

of stools. 


Soap. 


Per cent, of total fat as 


Type of stools. 


Free fatty 
acids. 


Neutral fat. 


Constipated 


36.0 
36.2 
31.9 
32.7 
30.2 
33.4 
40.7 

18.0 


73.8 
72.8 
59.8 
44.6 
30.6 
12.4 
8.8 

45.1 


17.6 
16.5 
24.5 
19.3 
16.6 
30.4 
38.1 

27.4 


9 


Normal 


9 4 


Softer than normal 

Not homogeneous 

Loose 


11.9 

22.5 
55 1 


Diarrheal 

Severely diarrheal 

Older children on mixed 
diet. Normal stools.. 


61.6 
56.4 

27.5 



TABLE II 





Type of 
stools. 


Total fat 
per cent, 
of dried 
weight 
of stools. 


Soap. 


Per cent, of total fat as 


Food. 


Free fatty 
acids. 


Neutral 
fat. 


Cow's milk 

Breast milk 


Normal 
Normal 


36.2 

42.1 


72.8 
57.8 


16.5 
26.3 


9.4 
15.9 



Loc. cit. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 45 

The most striking thing about this series of figures is the 
gradual diminution in the percentage of soap, and the rise in 
fatty acid and neutral fat as the stools become diarrheal. 

It will be seen that the stools of the bottle-fed baby contain 
a higher percentage of soap and less fatty acid than those of 
the breast-fed baby. This goes back to the principle of "soap 
in an alkaline medium, fatty acid in an acid medium." The 
stools of a breast-fed baby are strongly acid on account of the 
relatively large amoimt of lactose and small amount of casein 
and calcium in breast milk. Those of a bottle-fed baby are 
likely to be alkaline on account of the relatively large amount of 
calcium and of casein in the food. 

Summary. — The chemistry of fat in the intestine is perhaps 
the most complicated and the most important of that of any of 
the food elements. It is complicated on account of the three 
different sorts of fat that are present (neutral fat, fatty acids, 
soaps) and on account of the variations in the action of these 
substances according to the conditions present, and the quanti- 
ties of the other food elements in the diet. It is important, 
because clinically failure of fat absorption represents one of the 
most important group of cases we are called upon to treat. 
There are so many theories concerned in the question of fat 
metabolism, so many varying views, and so much that we do 
not as yet understand clearly, or only half understand, that I 
have not attempted to give any extensive review of the literature, 
and the foregoing is only a brief outline of the subject. It 
should be enough, however, for a practical working knowledge. 

3. The Metabolism of Carbohydrate. — In contradistinction 
to fat, carbohydrate is necessary to life: if a baby is fed on a 
carbohydrate-free diet for any length of time he dies from acid- 
osis, on account of the abnormal and incomplete combustion 
of body fat with the resulting acetone bodies — diacetic acid, 
beta-oxybutyric acid, and acetone. A certain amount of car- 
bohydrate is necessar}'- to insure proper fat combustion. The 
exact minimum necessary for babies of different weights and 
ages is not known. Sugar is of great importance as a nitrogen 



46 PRACTICAL INFANT FEEDING 

sparer, and has more power in this regard than does an iso- 
dynamic amount of fat. When carbohydrate (sugar) is given in 
the diet it is possible to establish nitrogen equilibrium at a 
much lower level than when protein alone or when protein and 
fat alone are ingested. Thomas^ showed that a diet containing 
the large amount of 18.4 gm. nitrogen did not suffice to keep the 
adult body in nitrogen equilibrium when no carbohydrate was 
given. The reason for this is that the protein food is drawn upon 
so heavily for fuel in the body that not enough is left for the 
needs of growth and repair. This holds even more for infants 
than it does for adults, as the nitrogen needs of infants per 
kilogram of body weight are considerably greater than those of 
older persons. The importance of sugar for fuel is shown in 
breast milk, in which 48.7 per cent, of the calories is furnished 
by the sugar. 

The Relation of Sugar to Gain in Weight and the Retention of 
Nitrogen and Salts, — The feeding of large amounts of sugar may 
cause a rapid increase in weight, provided the sugar is well 
digested. This is partly due to water retention, and high sugar 
feeding is particularly likely to bring this about because the 
deposition of glycogen in the body cells, which may be con- 
siderable after high sugar feeding, is possible only when accom- 
panied by a retention of two or three times its amount of water. 
The considerable salt retention with high sugar feeding may 
also account for a part of the water retention. Thus we see 
many babies who have been fed on a one-sided high sugar diet 
who appear fat, and are perhaps above normal weight. The 
apparent robust health and weight in these cases is deceptive 
because it does not consist of healthy fat and muscle, but of 
water which has been retained in the body cells. Condensed 
milk babies are likely to be of this type. 

Sugar is not without a good deal of influence upon the reten- 
tion of the other food elements; up to a certain point the more 
sugar that is fed, the greater is the retention of nitrogen and 
salts, particularly of nitrogen. If the tolerance for sugar is 
1 Arch. f. Physiol., Suppl., 1910, p. 249, 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 47 









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48 PRACTICAL INFANT FEEDING 

overstepped, and fermentation results, the retention of nitrogen, 
and especially of salts, may be greatly diminished. This is of 
considerable importance in practical infant feeding and is 
illustrated in Table III, from some investigations carried out 
by Dr. Fritz Talbot and myself in 19 14.^ The effect on the 
retention and absorption of the other food elements of gradually 
increasing the amounts of sugar in the diet of a six months' 
old baby was studied in several metabolism periods of three 
days each. In the first three periods the baby was doing well, 
his absorption was good, and as the sugar in his diet was in- 
creased there was an increasing retention of nitrogen and gain 
in weight. In Period IV his sugar tolerance was overstepped, 
and he reacted with loose, green, acid stools, causing a poor 
absorption of all the food elements, a great increase of neutral 
fat in the stools, and a negative ash and nitrogen balance. 

Digestion and Absorption of Sugar, — ^The three common 
sugars used in infant feeding — lactose, sucrose, and dextrin — 
maltose preparations, are disaccharids of complex formula, and 
must undergo splitting in the intestinal tract before being 
absorbed. Glucose is a monosaccharid, and is absorbed as such 
without further digestion. It is probable that sugar is normally 
acted upon very little in the stomach. It is broken down in 
the small intestine by the intestinal ferments into two molecules 
of a monosaccharid, and is absorbed as such. For each sugar 
there is a specific ferment: for lactose, lactase; for maltose, 
maltase; and for sucrose, invertin. The absorption of sugar in 
health is excellent, and most investigators have been imable 
to find sugar in the stools of normal babies. In cases where 
sugar is not being well absorbed, it is broken down by bacterial 
action into acid end-products, and thus, even in sugar indiges- 
tion, it is not usual to find sugar in the stools. If there is excess- 
ively vigorous intestinal peristalsis, and large amounts of sugar 
are ingested, the sugar may be hurried through so quickly that 
the unabsorbed residue may not have time to be completely 
fermented, and small amounts may be found in the stools. 
1 Amer. Jour. Dis. Chil., vol. 8, September, 1914. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 49 

Normal Action of Sugar in the Intestine. — In the breast-fed 
baby there is always a certain amount of sugar fermentation 
going on in the large intestine caused by the fermentative 
acidophilus and bifidus flora. Lactic acid and to a certain extent 
acetic and other volatile acids are the end-products of the 
fermentation, and serve to promote peristalsis and consequent 
evacuation of the bowel. In the large intestine of the bottle-fed 
baby, however, putrefactive processes predominate, and under 
normal conditions sugar fermentation is not so extensive. It 
has been shown that a slight amount of sugar fermentation in 
the large intestine is beneficial, and that the absorption and 
retention of the other food elements is aided by it. Large 
amounts of sugar in the food are likely to cause loose stools; 
the lack of sugar favors constipation. 

Assimilation Limits of Different Sugars. — ^A baby takes rela- 
tively much more sugar than does an adult, and the assimilation 
limit, or the amount of sugar ingested per imit of body weight 
before sugar appears in the urine, is much higher in infancy 
than it is in later life. A breast-fed baby of 4 gm. would nor- 
mally take perhaps 120 gm. of milk at a feeding, containing, 
roughly, 8.4 gm. of lactose, or 2.1 gm. per kgm. of body weight.^ 
An adult usually shows sugar in the urine after taking about 
1 gm. of sugar per kilogram of body weight. 

Langstein and Meyer have calculated that an adult of 150 
pounds would take about 800 gm. of sugar per day if he took as 
much in proportion to his weight as a 12-pound breast-fed baby. 

Practically speaking, it is difficult to exceed the assimilation 
limit of a baby before sugar fermentation and diarrhea occur. 

Porter and Dunn^ in a series of cases fed large amounts of 
sugar to babies (from 7 to 18 per cent., or 90 to 225 gm. in 
twenty-four hours) with the purpose of determining how much 
sugar could be taken without digestive upset and also if the 
assimilation limits could be exceeded before diarrhea occurred. 

> Langstein and Meyer, Sauglingsernahrung und Sauglingsstoffwechsel, 
Weisbaden, 1910. 

2 Amer. Jour. Dis. Chil., vol. 10, No. 2, 1915. 

4 



50 PRA.CTICAL INFANT FEEDING 

They found that surprisingly large amounts could be taken 
without digestive disturbance, and although sugar occurred in 
the urine in some cases during the course of sugar diarrhea, its 
occurrence bore no relationship to the amount of sugar ingested. 
They conclude that much larger quantities of sugar can be taken 
without the development of intolerance than has been ordinarily 
supposed, and that it is not possible to exceed the sugar assimila- 
tion limits, so that sugar occurs in the urine before symptoms of 
sugar indigestion have occurred. 

The assimilation limits of the different sugars vary some- 
what, that of lactose and sucrose being about equal, from 3.1 
to 3.6 gm. per kilogram of body weight, that of maltose con- 
siderably higher, about 7 gm. 

Sugar Fermentation. — It is now generally granted that bac- 
terial fermentation of sugar in the intestine plays a very impor- 
tant part in digestive and nutritional disturbances. A number 
of different agencies may bring this about, but the end-result is 
the same: excess of acid from the breaking down of the sugar, 
with consequent irritation of the intestinal mucous membrane. 
The production of acid is the first step in the chain of processes 
which may occur, and which may produce mild or severe con- 
ditions in the baby, depending upon how far they are allowed to 
go. It is probable that the unchanged sugar molecule is with- 
out much influence, and that it must be broken down into 
volatile acids before harmful results are brought about. This 
chemical change is produced by the action of bacteria upon 
sugar, and it is probable that it cannot be done in any other 
way. 

Let us consider for a moment the chemistry of sugar fer- 
mentation, and the products that are formed. Lactose is a 
disaccharid, a rather complex chemical substance, with the 
formula C12H22O11, containing many carboxyl and some aldehy3 
groups which may be very readily changed over into acid 
radicals. It will be seen from this that there is possibility for 
the formation of a considerable number of end-products when 
the molecule is torn apart, and that from the chemical con- 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 5 1 

stitution of sugar acids are the substances which are most 
likely to be formed. Two different groups of acids may result 
from the breaking down of sugar: the so-called volatile "fatty" 
acids and the non-volatile acids. The non-volatile acids are 
lactic and succinic acids and probably do no harm. It is the 
volatile fatty acids with which we are chiefly concerned. There 
are thirteen members in this acid series, as follows: 

Name of acid.^ Formula. 

Formic HCOOOH 

Acetic CH3COOH 

Propionic CsHeOa 

Butyric C4H8O2 

Valeric C6H]o02 

Caproic C6H12O2 

Heptylic C7H14O2 

Caprylic C8H16O2 

Nonylic C9H18O2 

Capric C10H20O2 

Palmitic C16H32O2 

Margaric C17H34O2 

Stearic C18H36O2 

The lower members are liquids; the higher ones, beginning 
with Cio, are solids at ordinary temperature. It is the lower 
members of the group which are most important, and it is 
unlikely that the higher ones are formed by the breaking dowa 
of sugar. The higher acids are formed by the breaking downi 
of fat, and it is also theoretically possible that the lower acids 
(formic, acetic) may be likewise formed from fat destruction. 
Probably always when there is a fermentation of sugar going on 
in the intestine there is also a secondary fermentation of fat, 
and it is quite impossible to tell how much of the acid formed 
comes from the one, how much from the other. The modern 
German school is inclined to attach very little importance to 
fat fermentation; they believe that it is practically always 
secondary to sugar fermentation and does little harm. Salge, 
in his important monograph in 1906, believed, however, that 
all the trouble came from the fat, and none from the sugar. 
1 Holleman, Text-book of Organic Chemistry. 



52 PRACTICAL INFANT FEEDING 

Chemically, both substances can form acids very easily, and it 
is probable that in many cases the sugar and the fat both play an 
important part. 

Bokai^ found that the acids were irritating to the intestine 
in the following order: caprylic, caproic, acetic, propionic, 
formic, butyric, valeric. Bahrdt and Bamberg^ believe that 
acetic is the most irritating. Increased amounts of volatile 
fatty acids in the intestine may bring about the following 
harmful changes: 

1. Increase peristalsis by irritating the intestine, with 
diarrheal stools as a result; these loose stools may carry out a 
good deal of imdigested fat and protein which have not had 
time for absorption. 

2. Injure the mucous membrane of the small intestine in 
such a way that it is unable to exert its normal antibacterial 
powers. Also, the functionally injured mucous membrane may 
allow the passage of harmful substances (lactose (?), salts, acids, 
or bacterial endotoxins) into the system, which would not be 
able to pass the healthy intestine. This may lead to severe 
intoxication, 

3. Draw upon the alkali reserve of the body in an attempt 
to neutralize the excessive acidity. This may help to cause an 
acidosis. 

4. Upset the normal chemical processes of digestion, most of 
which cannot go on satisfactorily in an excessively acid intestine. 

Conditions Which Bring About Sugar Fermentation. — ^Two 
things are necessary for sugar fermentation: imdigested sugar 
free in the intestine and bacteria in sufficient quantity to attack 
it. It must be remembered that there is no specific bacterium 
which accomplishes this; it may be done by a number of differ- 
ent organisms, either the normal inhabitants of the intestine or 
harmful organisms introduced from without. The place of 
fermentation is of a good deal of importance; in the breast-fed 
baby fermentation in the large intestine is normal; in the bottle- 
fed baby who is sick on account of sugar fermentation the process 

1 See Tobler, ref. 566. 2 Ztsch. f. Kinderheilk., 3, 322, 1911, 1912. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 53 

may be taking place in the small as well as in the large bowel. 
A difficult problem in artificial feeding is to keep down excessive 
intestinal putrefaction, with the formation of constipated alkaline 
calcium soap stools, without going to the extreme of excessively 
acid sugar fermentation. These two conditions are largely 
controlled by the relation between the different food elements 
in the mixture offered to the baby. (See section on Bacteriology.) 
The following seven conditions may produce abnormal sugar 
fermentation. I shall discuss in this section only the last one — 
high sugar in combination with high salts — and will take up the 
others in subsequent chapters. 

1. Bacteria introduced from without in bad milk. 

2. Overfeeding with sugar. 

3. Overheating of the baby's body. 

4. "ParenteraP' infections. 

5. Nervous influences. 

6. Constitutional weakness. 

7. High sugar in combination with high salts. 

The German school has contended that perhaps the most 
important cause of sugar fermentation is a depression of the 
antibacterial powers of the epithelial cells of the small intestine 
by the salts of the cow's milk, particularly those salts which 
are left behind in the whey after the curd has formed. This 
lowering of resistance allows bacteria to flourish in the small 
intestine where they would not normally be able to exist except 
in very small nimibers. It is an ingenious attempt to explain 
many little understood phenomena, but does not rest upon a 
firm enough substratimi of observation and investigation to be 
unconditionally accepted as the truth. The importance ascribed 
to the whey salts is based largely upon Meyer's investigation, 
in which he separated breast milk and cow's milk each into 
curds and whey, and then added the whey of breast milk to the 
curds of cow's milk, and vice versa. He found that the mixtures 
containing the cow's whey caused diarrhea when fed in con- 
junction with a high sugar; those containing the whey of breast 
milk did not. 



54 PRACTICAL INFANT FEEDING 

There is no question that cows' whey is rich in salts. It con- 
tains about 0.80 to 0.90 per cent, salts, in the form of chlorids, 
citrates and phosphates of sodium, potassium, and calcium. 
About half of the calcium of the original milk is present in the 
whey; probably nearly all of the sodium and potassium.^ There 
is a certain amount of evidence to show that strong solutions of 
salts may depress the functions of living cells, but the salt con- 
centration of cow's whey, although higher than that of human 
whey, corresponds to a physiologic saline solution only. It is 
hard to see how a concentration of salts which is thus practically 
isotonic with the body fluids can act in an injurious manner to 
the intestinal cells. Again, we know that plain whey, undiluted, 
is usually borne very well by even the smallest babies, and often 
is fed to them with great success during gastro-intestinal dis- 
turbances of various sorts, when the casein and fat of cow's 
milk, perhaps, cannot be borne at all. Also when we add sodiiun 
citrate in the strength of 1 or 2 grauis to the ounce of milk and 
cream in the mixture, to modifications to favor the digestion of 
the protein, we are adding a large amount of sodium and of 
citrate ions, which does not seem to upset the baby. Again, 
when we add calcium chlorid to a baby's milk in order to lessen 
nervous irritability in spasmophilia, we add much more than is 
ever present in whey. Neither does this ordinarily upset the 
baby. 

One of the chief purposes of the famous "Eiweissmilch" was 
to dilute the whey salts, but in eiweissmilch we have all the 
salts of the buttermilk used in its preparation, which in the 
finished eiweissmilch would correspond approximately to a salt 
concentration obtained by dilution of cow's milk one-half with 
water. Eiweissmilch works; there is no question of that; 
but is not its beneficial effect due rather to a very low sugar 
content (1.5 per cent.) than to a low salt content, which it does 
not contain? Let us suppose a baby was having dyspepsia on a 
dilution of one-half milk with added sugar; we would feed him 
eiweissmilch, and it would probably arrest the sugar fermenta- 
1 Bosworth: Personal communication. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 55 

tion, but we would not have decreased the salt content of his 
food at all. 

The work of Courtney and Fales/ under the direction of Dr. 
Holt, is interesting in this connection: 

"Protein milk contains a higher ash and higher amount of all 
the different salts than are ordinarily given to infants artificially 
fed. As compared with woman's milk, not only are the total 
salts of the ash in great excess, but the amount of calciiun is 
nearly five times and the phosphorus nearly seven times as 
great. The soluble salts, also, are nearly twice as abundant in 
protein milk as in human milk. As used at the Babies' Hospital 
extensively for three years, with most satisfactory results, eiweiss- 
milch has contained, owing to the addition of sodium chlorid to 
the buttermilk used, an amount of Na and CI nearly as great as 
in undiluted cow's milk, and much greater than in woman's milk. 
The following table shows the salt content in percentages of 
protein, cow, and human milk": 

Total ash. CaO. MgO. P2O8. K2O. Na20. CI. 

Protein 648 .201 .021 .222 .109 .032 .061 

Cow 743 .176 .020 .206 .189 .050 .111 

Human 206 .047 .008 .034 .057 .014 .035 

It can be seen from these few suggestions that the question 
of the harmfulness of the whey salts is not at all a clear one, and 
that Meyer's original suppositions can be by no means uncon- 
ditionally accepted. There is no question that breast milk, 
even with its high sugar content, can often be fed with beneficial 
results to babies who are suffering from sugar fermentation. 
Sugar fermentation must, therefore, be due in these cases to 
sugar plus some indeterminate factor present in cow's milk and 
not present in breast milk. There is evidently some property 
of breast mUk which allows its high sugar content to be handled 
by the baby without undue fermentation; whether this is due to 
the relatively low salt content of breast milk or to other factors 
is by no means certain. 

1 Amer. Jour. Dis. Chil., vol. 10, 1915, p. 172. 



56 PRACTICAL INFANT FEEDING 

Starch is a polysaccharid, a more complex fonn of carbo- 
hydrate than the sugars, and must be broken down into sugar 
before it can be absorbed. Its absorption is, therefore, slower 
than that of the sugars. It is probable that mouth digestion of 
starch is very slight in young babies, although the saliva has 
been shown to contain active ptyalin. The amylopsin of the 
pancreatic juice breaks down the starch first into dextrins, then 
into maltose, and the maltose is in turn changed to dextrose by 
the maltase of the succus entericus, and is absorbed as such. 
All the starch-splitting ferments have been found at birth, 
although their power is feeble during the first few months, 
and they do not become strongly developed until the end of 
the first year. Absorption of starch when given in moderate 
amounts, as cereal gruels to young babies, is good, and it is 
probably true that starch in this form could be used with 
advantage a good deal earlier than it usually is. 

If starch is not well digested, it either comes through the 
stools as a foreign body, partly or entirely digested, or may be 
attacked by the intestinal bacteria and slowly fermented, with 
resulting end-products consisting mostly of volatile acids. 

4. The Metabolism of the Mineral Salts. — ^The salts are of 
very great importance in the normal and abnormal processes of 
infant nutrition, and in the last fifteen years especially an 
enormous literature has grown up regarding them. So much 
has been written, so varying have been and still are many of the 
opinions held and the figures given, so complicated is the ques- 
tion of the metabolism of any individual miaeral element, to 
say nothing of its relations to the other salts and the organic 
elements of the diet, that it is hard indeed to separate the wheat 
from the chaff, and to present in a clear and non-tedious way 
what seem to be the main facts of the subject that are of interest 
to practical medical men. 

It is probably true that the clinical pictures produced by 
many "food injuries" are due very largely to disturbed salt 
metabolism, and in certain instances it is possible to know with 
a fair degree of accuracy what has brought about this perversion, 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 57 

and how to correct it by changes in the diet, but in general there 
are far more theories concerned in discussions of disturbances in 
salt metabolism than well ascertained and universally accepted 
facts, and it is not ordinarily possible in practical infant feeding 
to vary the amounts of the various mineral elements in the food 
offered to the infant with the same degree of accuracy that we 
vary the organic constituents. 

Cow's milk contains a much larger quantity of mineral 
material than does human milk, about 7.8 gm. to the liter for 
the former, 2 gm. to the liter for the latter. The salt metab- 
ohsm of the bottle-fed infant is, therefore, on an entirely different 
plane from that of the breast fed. The salts are in much the 
same relative proportions in cow's milk as in human milk, with 
the exception of phosphorus and iron. 

According to Holt, Courtney, and Fales- 100 gm. of ash 
contain the following: 





CaO. 


MgO. 


P2OJ. 


NazO. 


K2O. 


Cl. 


Human milk . 


. 23.3 gm. 


3.7 gm. 


16.6 gm. 


7.2 


28.3 


16.5 


Cow's milk. . . 


. 23.5 « 


2.8 « 


26.5 « 


7.2 


24.9 


13.6 



Iron is the only mineral element that is present in smaller 
quantities in cow's than in human milk. There are three especial 
points which must be borne in mind in reviewing the question of 
salt metabolism: 

1. The analytic methods that have been used have often 
been faulty (especially for calcium and iron), and, therefore, 
many of the older figures are not accinrate. 

2. Often reports have been made on the salt metabolism of 
one infant over a relatively short period of time, and these 
figures have been used as liie standard, being passed on from 
book to book. 

3. A large portion of the intake of mineral salts (especially 
calcium) is re-excreted in the intestine after absorption; there- 
fore it is not possible to get any accurate figures as to the 
amounts which have actually been absorbed. This must be 

1 Amer. Jour. Dis. Chil, vol. 10, 1915. 



58 PRACTICAL INFANT FEEDING 

borne in mind in considering the figures for absorption, whether 
for total ash or for individual salts, and by "absorption" is 
ordinarily meant the difference between the intake and what 
appears (either re-excreted or unabsorbed) in the stools. 

Physiologic Importance of the Salts. — ^Hoobler^ has summa- 
rized very clearly the physiologic importance of the salts: 

"(1) They maintain the osmotic pressure in tissue cells, 
blood, and body fluids; controlling the flow of water to and from 
the tissues; any deviation from normal causing a shrinking or 
swelling of tissue cells. 

"(2) They regulate the reaction of the blood and tissue 
fluids. A deviation from this reaction inhibits the action of the 
various ferments, delays chemical processes, and, if such reaction 
suffers much variation, death results (acidosis). 

"(3) Their presence in tissues and fluids gives rise to irri- 
tability of muscle and excitability of nerve through the action 
of their respective ions. Through this function the rhythmic 
contractions of the heart are maintained. 

"(4) They act as catalysts for a large series of chemical 
reactions which take place during the processes of absorption, 
retention, utilization, and form combinations with waste prod- 
ucts of metabohsm in order to effect their elimination; for 
example, they act as carriers of excess acid materials in oxidation 
processes. 

"(5) They share in the upbuilding and growth of the body, 
since they are a constituent of every cell; particularly do they 
take part in the changes which go on in the albumin bodies as 
they become intimately bound with the body proteins. 

"(6) Their fuDction in the intermediary metabolism of the 
ductless glands is very apparent from the large quantities of 
mineral salts found in these organs. 

''(7) Through a most excellent self-regulation they protect 
against the acid poisons which the body is constantly producing. 

"(8) Through the work of the various ions, electrically 
charged, some positively, some negatively, many important 
lAmer. Jour. Dis. Chil., vol. 2, 1911. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 59 

functions are being assigned to them, such as contr6lling body 
weight, temperature, regulating the pulse, increasing leukocytes, 
etc. These and msiny more functions, not clearly defined, 
depend upon the presence of the mineral salts in the body, and 
not on their presence alone, but their presence in definite rela- 
tionships to one another." 

(9) They form an important part of all the digestive juices. 
(L. W. H.) 

Total Ash. — 1000 c.c. of cow's milk contains 7.8 gm. of total 
ash; 1000 c.c. of human milk contains 2 gm. of total ash. 

The absorption of ash is not so good as that of the inorganic 
food elements. According to different observers, the percentage 
absorption varies from 65 to 75 per cent, in the bottle-fed 
babies, and is somewhat higher for the breast fed. The actual 
absorption is higher in the bottle fed. 

In any diarrhea the absorption may be very poor, so that 
there is an actual negative salt balance, with a loss of mineral 
substance from the body. This is important clinically and un- 
doubtedly has a great deal to do with the clinical picture seen 
in severe cases of diarrhea. 

Calcium and Magnesium. — 1000 c.c. of human milk contains 
0.42 gm. of CaO and 0.082 gm. of MgO; 1000 c.c. of cow's milk 
contains 1.72 gm. of CaO and 0.20 gm. of MgO. 

Calcium is present in cow's milk in three different forms 
(Bosworth^) : 

1. As insoluble phosphate, which is practically inert, is not 
absorbed, and is recovered in the stools as such. 

2. Combined with protein as calciiun caseinate. 

3. As soluble salts in the whey. 

It is not possible to tell accurately how much calcium is 
actually absorbed, as the excretion of calciiun in the bottle fed 
takes place almost entirely through the intestine, and only a 
small amount is excreted through the urine. According to Bos- 
worth the calcium metabolism of the bottle-fed baby is seldom 
greater than that of the breast-fed baby, and may actually be 
1 Amer. Jour. Dis. Chil., vol. 15, 1918. 



6o PRACTICAL INFANT FEEDING 

less, even if there is more calcium in the food, as most of the 
calcium is eliminated in the feces as insoluble calcium phosphate 
and calcium soaps. 

Breast baby Bottle baby 

(gm. per 240). (gm. per 240). 

CaO in urine 0. 069 gm. 0. 025 gm. 

CaO in feces 0.038 " 1.672 « 

The figures given for the absorption of calcium vary so 
much that it is impossible to draw any very exact conclusions 
from them. The methods used for analysis, the age and nutri- 
tional condition of the baby, the amoimt of calcium in the food, 
and its relation to the other food elements probably account for 
these differences. From a study of the figures available it would 
seem that the percentage absorption in babies fed on cow's 
milk is low, and that the percentage absorption, although not 
the actual absorption, is certainly a third greater, and perhaps 
nearly twice as great in the breast fed as in the bottle fed. The 
latest and probably the most reliable work is by Holt, Courtney, 
and Fales,^ who found that bottle-fed babies absorbed from 
35 to 55 per cent, of the intake, while breast-fed babies absorbed 
66.7 per cent. 

"The average absorption of CaO for 5 healthy breast-fed 
babies was foimd to be 0.054 gm. per kilogram. Since infants 
taking cow's milk absorb only about 45 per cent, of the calcium 
intake, it is necessary to provide for them a minimum intake of 
0.130 gm. CaO per kilogram of body weight in order to have 
them absorb as much as a breast baby." 

Since cow's milk contains on an average of 1.72 gm. CaO per 
liter, I liter of milk would amply cover the calcium needs of a 
baby of 6.5 kgm. or about 14| pounds. A baby of about 20 
pounds would require, according to these figures, 1.17 gm. CaO 
per day, and would be getting considerably more than this in a 
liter of milk. If these figures are correct there is, therefore, little 
danger of not covering the calcium needs of infants with the 
ordinary methods of feeding, especially as usually after the eighth 

1 Loc. cit. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 6 1 

or ninth month cereal is added to the diet, which contains a not 
inconsiderable amount of calcium. 

The three pathologic conditions which are of most impor- 
tance in connection with abnormal calcium metabolism are 
chronic fat indigestion (Bilanzstorung), rickets, and spasmo- 
philia. Rickets and spasmophilia will be discussed later. 

The relation of calcium excretion to the fat in the diet has 
long excited interest, and many metabolism experiments have 
been carried out to determine what effect increasing amounts of 
fat in the diet had upon calcium absorption. The consensus of 
opinion seems to be that increased fat in the diets of normal 
babies does not decrease calcium absorption (Holt, Courtney 
and Fales,^ Meyer ,^ Aschenheim^). 

As regards babies who have a chronic incapacity for fat, 
particularly those who pass the colorless, dry, constipated stools 
which contain a large excess of soap, the conditions are quite 
different, and there may be a large loss of calcium in such stools, 
enough in many cases to cause a negative calcium balance. 
According to Meyer,* in Bilanzstorung (chronic fat indigestion) 
as much as 60 per cent, of the calcium intake may be lost in 
these stools, but soap stools in themselves do not always mean 
that there is an increased calcium output or a negative calcium 
balance. One can only say that very frequently when typical 
soap stools are passed there is a negative calcium balance. Bos- 
worth, Bowditch, and Giblin^ believe that the large excess of 
calcium in cow's milk is the prime reason why certain infants 
suffer nutritional disturbance when considerable amounts of 
fat are taken, and they have shown in these cases that it is possi- 
ble by feeding a decalcified milk to greatly increase the tolerance 
toward fat. In one of their cases the total fat in the stools 
dropped from 4 gm. per day to 0.66 gm. per day as soon as the 
feeding with decalcified milk was started, and they have found 

1 Amer. Jour. Dis. Chil., vol. 19, 1920. 

2 Jahrb. f. Kinderh., 71, 1, 1910. 

3 Ibid., 77, 1913. 
^ Loc. cit. 

5 Amer. Jour. Dis. Chil, vol. 15, 1918. 



62 PRACTICAL INFANT FEEDING 

that many infants who on ordinary milk mixtures are able to 
handle practically no fat at all, thrive on as much as 3 per cent, 
when the decalcified milk preparation is used. In spite of much 
research on the subject the interaction of fat and of calcium and 
their relative importance in chronic fat indigestion are still 
obscure. We know that in many cases where there is poor util- 
ization of fat there is also pure utilization of calcium; we know 
that the simple loss of calories from the poor fat absorption is 
not enough to account for the disturbance of nutrition; we know 
that the loss of calciiun is not entirely accounted for by a simple 
binding with fatty acid to form insoluble calcium soaps; still, 
the characteristic nutritional change does not occur unless fat 
and calcium are both present in relatively large amounts, and 
it never occurs in infants fed on breast milk, where the fat is 
high and the calcium is low. About all that can be said in the 
present state of our knowledge is that in some babies high fat 
plus high calcium is not well tolerated. 

Magnesium. — There is only a small amount of magnesium in 
either cow's or human milk. It is not so important as calciimi 
in the pathogenesis of nutritional disturbances, but being closely 
allied to it chemically, in general acts in the same way, and 
forms insoluble soaps with fatty acids. The percentage absorp- 
tion of magnesium is about the same as that of calcium. 

Sodium and Potassium. — 1000 c.c. of cow's milk contains 
0.46 gm. of Na20 and 1.72 gm. of K2O; 1000 c.c. of human 
milk contains 0.16 gm. of Na20 and 0.88 gm. of K2O. 

The absorption of both sodium and potassium is relatively 
better than that of the other salts, from 75 to 90 per cent, of the 
intake being absorbed. They are excreted partly through the 
urine as phosphates and chlorids, and partly through the intestine 
(digestive juices) . In diarrhea the sodium and potassium absorp- 
tion especially suffers, and there may be a negative balance^ 
while the calcium and magnesium balance is positive. With 
constipation, especially of the soap stool type, there is likely to 
be a good and perhaps in certain cases an excessive retention of 
sodium and potassiimi. There is normally a certain fairly defi- 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 63 

nite balance between the amount of sodium and potassium in 
the body, on the one hand, and the calcium and magnesiiun on 
the other hand, which is necessary to preserve the proper degree 
of nerve irritability. If too little calciimi and magnesium and 
too much sodium and potassium are retained, a condition of 
increased nerve irritability is likely to result (see Spasmophilia). 
Sodium and potassium are also important in furnishing alkali 
for the pancreatic and intestinal digestive juices, and for the 
bile. 

Phosphorus. — 1000 c.c. of cow's milk contains 2.25 gm. of 
P2O5; 1000 c.c. of human milk contains 0.40 gm. of P2O5. 

Phosphorus is needed especially by the body for the forma- 
tion of bone, glandular tissues, and the central nervous system. 
Part of the phosphorus present in milk is in organic form con- 
tained in the milk casein, partly in inorganic form. In cow's 
milk a large part of the phosphorus exists as insoluble calcium 
phosphate, which is inert as far as metabolism is concerned, and 
goes through the intestinal tract quite without absorption 
(Bosworth). In cow's milk a much greater amount of phos- 
phorus is present than can possibly be used by the baby, and the 
percentage absorption is not nearly so high as that of the phos- 
phorus contaiaed in breast milk, although the actual absorption 
may be more. The figures given by various authors for phos- 
phorus absorption vary between 53 and 83 per cent, for cow's 
milk and 65 and 89 per cent, for human milk. The breast-fed 
baby excretes only traces of phosphorus in the urine, and the 
bottle-fed baby may excrete a fifth or a sixth as much in the 
urine (0.34 gm.) as he does in the stools (1.67 gm.) (Bosworth). 
According to Hoobler the elimination through the urine and 
intestine is about equal. 

Iron. — 1000 c.c. of cow's milk contains 0.0006 gm. of Fe203; 
1000 c.c. of human milk contains 0.0017 gm. of FeoOs. 

On account of faulty methods of analysis there seems no 
question that the older figures given for iron were altogether 
too high, and that both human and cow's milk contain only 
very small amounts. It is the only mineral element which is 



64 PRACTICAL INFANT FEEDING 

present in smaller quantities (one-third as much) in cow's milk 
than in human milk, and when cow's milk is diluted, as it is in 
infant feeding, the amount of iron present is almost negligible. 
Despite this, babies seem to thrive during the first eight or nine 
months, at any rate, on dilutions of cow's milk which contain 
practically no iron. It is a clinical fact that babies after this 
time are likely to become anemic, whether bottle or breast fed, 
if additional iron-containing food is not given. This is especially 
true of premature infants and twins. It is well known that the 
newborn infant contains a considerable store of iron in the liver, 
which probably acts as a reserve depot, and it is supposed that 
this accounts for the fact that the bottle-fed baby gets along 
on a food containing only traces of this element. The iron 
needs of babies are not definitely known, and the only data 
available is the iron intake of the naturally fed infant, who is 
supplied about 1.5 mgm. Fe203 per day in his ration of breast 
milk. Soxhlet^ calculated that if a baby gained 25 gm. in weight 
a day there would be a daily gain of 1.92 gm. of blood, which 
would require 1.34 mgm. of iron oxid. This amount is well 
covered by the breast milk. It is likely that in the early months 
of life more iron is excreted than is taken in (Blauberg, Camerer), 
and as long as the fetal iron deposit in the liver is taking part in 
the iron metabolism it is not possible to determine the amount 
or iron absorbed or retained. 

From a practical point of view it seems certain that the iron 
in the liver plus the very small amount contained in cow's milk 
modifications is enough to cover the iron needs of artificially fed 
babies for the first eight or nine months at any rate. These 
needs must, therefore, be very small, and if after the eighth 
month food is added which contains only a very small amount of 
additional iron, there is no danger of anemia developing. 

Sulphur, — 1000 c.c. of cow's milk contains 0.33 gm. of SO3 
(Hoobler); 1000 c.c. of human milk contains 0.14 gm. of SO3 
(Blauberg). 

According to Hoobler the percentage of sulphur absorbed 

1 Munch, med. Woch., vol. 59, 1912. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 65 

varies from 88 to 95 per cent. Most of the sulphur in milk is a 
constituent of the casein. 

Chlorids. — 1000 c.c. of cow's milk contains 0.82 gm. of CI; 
1000 c.c. of human milk contains 0.34-0.59 gm. of CI. 

The absorption is from 90 to 95 per cent, of the intake. The 
excretion is largely through the urine, as sodium chlorid, except 
in diarrhea, when considerable amounts may be lost in the stool. 

5. The Vitamins.^ — It is now recognized that, in addition 
to fat, carbohydrate, salts, and water, food-stuffs contain other 
substances which are necessary for proper growth and main- 
tenance. These substances have been variously called "vita- 
mins," "accessory" food factors, and "fat-soluble A," water- 
soluble "B" and "C." In 1897 Eijkman, who was studying the 
Eastern disease beriberi, found that pigeons who were fed solely 
upon polished rice developed in three or four weeks a condition 
of paralysis, which was a polyneuritis, and was analogous to 
beriberi in man. When instead of being given polished rice 
they were fed upon whole rice kernels they did not develop beri- 
beri, and, furthermore, it was found that the administration of 
rice poUshings would cure the disease after it had developed. 
The natural inference was that it was caused by a lack of some 
unidentified substance or substances contained in the rice 
polishings. In 1912 Hopkins foimd that maintenance of body 
weight and growth in rats could not proceed with a diet of 
purified food substances, but that if milk was added growth 
proceeded. He suggested the existence of imidentified food 
substances which were supplied by the milk, and gave them the 
name of "accessory" food factors. In 1914 Funk called these 
substances "vitamins" and believed that beriberi, scurvy, and 
rickets were caused by a lack of them in the diet. McCollimi 
and Kennedy, who had been for some time working along 

1 Only a very brief outline of this fascinating subject is possible here. 
If the reader desires to go further with it he is referred to that most inter- 
esting book of E. V. McCoUum's, "The Newer Knowledge of Nutrition" 
(Macmillan Co., 1918), of which I have made free use in this section, and to 
the Journal of Biological Chemistry, 1915-1921, in which most of the original 
articles concerning the vitamins have appeared. 
S 



66 PRACTICAL INFANT FEEDING 

the same lines, believed that there were two substances, and 
suggested for them the names fat-soluble "A" and water- 
soluble "B." Still later a third substance was beKeved to be 
present, and was called water-soluble "C." While it is true that 
the word "vitamin" has certain objections as a term of nomen- 
clature for these substances, it is the one most commonly used 
to designate them collectively. The individual vitamins are 
best spoken of as fat-soluble "A,'' etc. 

Nature and Occurrence of the Vitamins. — ^The chemical con- 
stitution of the vitamins is unknown, and they have never been 
isolated in pure form. Funk believed that they were nitrogenous 
bodies chemically allied to the amins, hence the term "vitamins." 
It is probable, however, that this view is erroneous, at least for 
the fat-soluble "A," as it occurs in fats, which contain no 
nitrogen. They cannot, apparently, be produced in the animal 
body unless food containing them is ingested, and the amount 
of vitamin in milk, for example, has been found to be directly 
proportional to the vitamin content of the food eaten by the 
cow. Fat-soluble "A" and water-soluble "B" are comparatively 
stable substances, not easily destroyed by heat or other agencies, 
while the water-soluble "C" is more easily destroyed by heat, 
oxidation, alkalies, or aging of the food in which it exists. Fat- 
soluble "A" occurs especially in butter fat, cod-liver oil, the fat 
of egg yolk, and the leaves of plants (spinach). It occurs to a 
slight degree in the roots of vegetables, such as carrots. It 
does not occur in vegetable oils, and only slightly in most 
animal fats, such as lard or beef fat. Water-soluble "B" is 
found especially in milk, the outer covering of the seeds of 
plants (rice, oats, wheat), and in brewer's yeast. Water-soluble 
"C" occurs especially in fruit juices and vegetables, and to a 
lesser extent in milk, germinated cereal grains, and meat. It 
does not occur in cereal grains that are not germinated. 

Action of the Vitamins. — Fat-soluble "A." — ^A lack of this 
in the diet causes lack of growth and a peculiar disease of the 
eyes called xerophthalmia, manifested especially by an inflam- 
mation of the cornea and possible blindness. Much experi- 



PHYSIOLOGY AND PATHOLOGY OP DIGESTION AND NUTEITION 67 

mental work has been done on animals (rats) by several investi- 
gators, with diets lacking the fat-soluble "A" factor, and failure 
of growth and xerophthalmia have been regularly produced. 
As soon as food-stuffs containing this factor are added to the 
diet, such as butter fat, cod-liver oil, or spinach, growth pro- 
ceeds, and the eye condition is cured in a very few days. It has 
been held by some that a lack of fat-soluble "A" is the cause of 
rickets, but this is by no means assured (see chapter on Rickets). 

Water-soluble "B." — ^A lack of this causes beriberi and 
possibly retarded growth. As far as is known it has no other 
specific action. 

Water-soluble "C." — ^A lack of this in the diet causes 
scurvy, which can be readily cured by the ingestion of food- 
stuffs (fresh milk, fruit juices, vegetables) which are rich in it 
(see chapter on Scurvy). 

Practical Importance of the Vitamins in Infant Feeding. — 
The subject is a new one, and, like all new discoveries in medi- 
cine, has been somewhat overdone. There is no question that 
there are such substances, the lack of which does produce cer- 
tain abnormal conditions, but there has been a great tempta- 
tion, especially in commercial quarters, to give the vitamin 
hypothesis undue prominence, and to assume that many condi- 
tions of ill being are dependent upon lack of vitamin in the diet. 

As regards infant feeding, we have in this part of the world, 
for practical purposes, only the fat-soluble "A" and water- 
soluble "C to consider, as beriberi (caused by a lack of water- 
soluble "B") occurs only in Eastern coimtries. 

It is quite conceivable that an infant or a child could receive 
in its diet too small an amount of fat-soluble "A." If the diet were 
fat free and vegetable free he would receive little of it, as it is 
contained in only very small quantities in fat-free milk. Or if 
the cows from which the milk came were fed on vitamin-poor 
diets, as they often are in the winter, their milk would in aU 
likelihood contain but small quantities of the vitamin. With 
breast feeding, Hkewise, the breast milk would be poor in this 
factor if the mother did not take sufficient quantities of butter 



( 



68 PRACTICAL INEANT FEEDING 

fat or of green vegetables. It is known, however, from clinical 
experience that it is possible to feed a baby on a practically 
fat-free diet over a long period of time without any apparent 
ill results, and it is probable that in the vast majority of in- 
stances breast milk or cow's milk even after it has been skimmed 
contains enough of the fat-soluble factor to prevent any unto- 
ward results. In times of famine, however, epidemics of xeroph- 
thalmia have been noted among children, and in the post-war 
German medical literature there are a number of papers describ- 
ing the ill effects of lack of fat in the diets of Austrian children. 
The relation of the fat-soluble vitamin to rickets has not yet been 
settled, but there is evidence to show that it may have some- 
thing to do with it, although not the essential cause. 

Most of the experimental work on the fat-soluble vitamin 
has been done with animals, and we have not at present suffi- 
cient knowledge as to how often it is lacking in the dietaries of 
infants and children, or what the exact effect of such lack may be. 

As a summary it may be said, however, that the experimental 
work on animals points the way, and that it can do no harm, 
and in all likelihood some good, for us to see to it that infants 
and children under our care receive an adequate amount of this 
accessory food factor. 

Water-soluble "C" (TIte Antiscorbutic Vitamin).— From a 
practical point of vievvr this is the most important vitamin con- 
cerned in infant feeding, as it is well established that a lack of it 
in the diet causes scurvy, which is not at all an uncommon con- 
dition. This will be discussed more completely in the chapter on 
Scurvy. 

It is probable that the diseases xerophthalmia, beriberi, and 
scurvy, caused respectively by a lack of fat-soluble "A," water- 
soluble "B'' and "C,'' represent the final pathologic condition 
brought about by a prolonged dietary deficiency, and that the 
earlier effect is manifested simply by general poor growth and 
nutritional state. Therefore, although xerophthalmia, beriberi, 
or scurvy may not be actually present, it may be possible that an 
undernourished child whose eating habits are peculiar may be 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 69 

suffering from vitamin deficiency, and it is thus advisable that all 
children as soon as they are old enough to take a mixed diet 
should have an adequate supply of milk, fresh vegetables, and 
fruit or fruit juices, which will supply in abundance the three 
vitamins. 

ENERGY REQUIREMENTS 

The caloric requirements of infants has been the subject 
of extensive study, with somewhat varying results. Food is 
looked upon as fuel, and is measured in terms of calories or 
heat units; the caloric requirements represent simply the num- 
ber of heat units per unit of body weight which it is necessary 
for the individual to ingest in order to thrive. 

The calorie used in infant feeding is the large calorie, and 
represents the amount of heat necessary to raise 1000 c.c. of 
water l"" C. 

One gram of fat furnishes 9 . 3 calories. 

One gram of protein furnishes 4. 1 calories. 

One gram of carbohydrate furnishes 4 . 1 calories. 

In calculating, the caloric requirements of infants and children 
must be taken into account:^ 

1. The basal requirement. 

2. Growth needs. 

3. Needs for muscular activity. 

4. Food value lost in excreta. 

The basal energy requirement represents that number of 
calories which is just sufficient to maintain life with the baby 
in complete repose, and is fairly constant in babies of the same 
weight. According to Morse and Talbot^ normal babies have a 
basal metabolism of between 52 to 63 calories per kilogram of 
body weight. Very fat babies have between 40 to 50, and most 
infants who are underweight have more than 65 per kilogram. 

The growth needs, the needs for muscular activity, and the 
food values lost in the excreta vary a great deal according to the 
baby. The growth needs of the infant during the first six months 

^ Holt and Fales, Amer. Jour. Dis. Chil., 1921, vol. 21. 

2 Diseases of Nutrition and Infant Feeding, New York, 1915. 



70 PRACTICAL INFANT FEEDING 

are greater than at any other corresponding period, as this is the 
time of most rapid growth. The needs for muscular activity 
are of great importance, and vary in different babies, according 
to whether they are active or sluggish. The newborn baby uses 
up relatively little energy in this way on account of his com- 
parative inactivity. 

An unusually nervous, active baby needs more calories than 
a phlegmatic, inactive one, and Howland has shown that simply 
hard crying increased the heat elimination 18 per cent, in one 
infant and 39 per cent, in another.^ 

The food value lost in the excreta of course varies somewhat 
with different babies, but in general is fairly constant, and is not 
so important a variable as is the muscular activity and the rate 
of growth. 

Heubner^ was the first to use the term "energy quotient,'^ 
and by it meant the number of calories per kilogram of body 
weight required per day. He estimated that the breast-fed baby 
needed in the first six months 100 calories per kilogram; that the 
artificially fed needed up to the third month 120, and that at 
the end of the first year from 70 to 80 was sufficient. 

Beck^ estimated that the energy quotient in breast-fed babies 
was as follows: 

First three months, 107. 

Second three months, 91. 

Third three months, 83. 

Fourth three months, 69. 
The results for breast-fed babies according to various observers 
have been somewhat conflicting, and are probably not very 
accurate, because the amount of breast milk taken has been 
determined by weight, and a constant composition assumed for 
it, which is probably not justifiable. 

Hoffman^ found an energy quotient in breast-fed babies 

1 Rowland, Amer. Jour. Dis. Chil., vol. 5, 1913, No. 5, 

2 Monatsch. f. Kinderh., 1904^5, iii, 206. 
8 Jahrb. f. Kinderh., 1910, Ixxii, 121. 

4 Arch. f. Gynakol., 106, 159, 1916. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 7 1 

(reckoning breast milk as 700 calories to the liter) of 113.8 for 
the first and second months, 96.5 for the third month, and 91.4 
for the fourth month. In the first four months the average 
energy quotient was 107.4, in the second four months 87.4. Von 
Jaschke,^ by careful daily determination of the amount of milk 
taken from the day of birth onward, assuming the liter of breast 
milk to contain 720 calories, found the following energy quotients: 

Day. Energy quotient. 

1 9.8 

2 17.9 

3 24 

4 41 

5 60 

6 72 

7 88 

8 108 

9 114 

10 119 

12 103 

21 122 

56 110 

75 102 

90 104 

98 105 

As regards the energy quotient in artificially fed babies, the 
results of most observers are so conflicting, and their con- 
clusions are so often founded upon inadequate data, that a 
summary of them would not be of value. 

The most extensive and most accurate work on the caloric 
requirements of infants and children has been done by Benedict 
and Talbot, and reported in many publications. Holt and Fales,^ 
with this work as a basis, to which they have added numerous 
observations of their own, have compiled what is probably the 
most accurate and useful tables of the caloric requirements of 
normal babies and children that have yet been published. These 
tables are reproduced on pages 72 and 73. 

1 Ztschr. f. Kinderh., vol. 16, June, 1917. 
8 Amer. Jour. Dis. Chil., vol. 21, 1921. 



72 



PEACTICAL INFANT FEEDING 



TABLE IV 
Calories Per Kilo^ for Boys 



Weight, 


Basal. 


Growth. 


Calories per kUo. 


Total 
calories 
daily. 


kilos. 


Activity. 


Excreta. 


Total. 


3 


46 


56 


8 


10 


120 


360 


4 


50 


52 


8 


10 


120 


480 


5 


54 


46 


8 


10 


118 


590 


6 


56 


38 


10 


10 


114 


685 


7 


57 


32 


11 


10 


110 


770 


8 


56 


28 


12 


10 


106 


850 


9 


56 


25 


12 


10 


102 


920 


10 


54 


22 


13 


10 


99 


990 


11 


53 


19 


14 


10 


96 


1060 


12 


52 


16 


16 


9 


93 


1120 


13 


51 


14 


17 


9 


91 


1180 


14 


50 


13 


17 


9 


89 


1240 


15 


49 


12 


17 


9 


87 


1300 


16 


48 


10 


18 


9 


85 


1360 


17 


47 


9 


19 


8 


83 


1410 


18 


46 


8 


20 


8 . 


82 


1470 


19 


45 


7 


21 


8 


81 


1540 


20 


44 


7 


21 


8 


80 


1600 


22 


42 


7 


23 


8 


80 


1760 


24 


41 


8 


23 


8 


80 


1920 


26 


39 


8 


25 


8 


80 


2080 


28 


38 


7 


27 


8 


80 


2240 


30 


Z6 


7 


29 


8 


80 


2400 


33 


35 


7 


30 


8 


80 


2640 


36 


33 


8 


31 


8 


80 


2880 


39 


32 


9 


31 


8 


80 


3120 


42 


31 


10 


31 


8 


80 


3360 


45 


30 


11 


31 


8 


80 


3600 


48 


30 


11 


31 


8 


80 


3840 


51 


29 


11 


31 


8 


79 


4030 


54 


29 


8 


31 


8 


76 


4100 


57 


28 


5 


30 


7 


70 


3990 


60 


27 


2 


27 


7 


62 


3720 


68 


25 





18 


5 


48 


3265 


(Adult) 















iKilo = 2.2 pounds. 



PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 73 

TABLE V 
Calories Per Kilo^ for Girls 



Weight, 


Basal. 


Growth. 




Calories per 


kilo. 


Total 
calories 
daily. 


kilos. 


Activity. 


Excreta. 


Total. 


3 


51 


51 


8 


10 


120 


360 


4 


53 


49 


8 


10 


120 


480 


5 


55 


45 


8 


10 


118 


590 


6 


56 


3S 


10 


10 


114 


685 


7 


56 


33 


11 


10 


110 


770 


8 


57 


27 


12 


10 


106 


850 


9 


56 


24 


12 


10 


102 


920 


10 


55 


21 


13 


10 


99 


990 


11 


53 


19 


14 


10 


96 


1060 


12 


51 


17 


16 


9 


93 


1120 


13 


49 


16 


16 


9 


90 


1170 


14 


47 


14 


17 


9 


87 


1220 


15 


45 


12 


19 


8 


84 


1260 


16 


44 


11 


19 


8 


82 


1310 


17 


43 


10 


19 


8 


80 


1360 


18 


42 


9 


19 


8 


78 


1400 


19 


41 


8 


20 


8 


77 


1460 


20 


40 


7 


21 


8 


76 


1520 


22 


38 


8 


22 


8 


76 


1670 


24 


37 


8 


23 


8 


76 


1820 


26 


36 


8 


24 


8 


76 


1980 


28 


36 


8 


25 


8 


77 


2155 


30 


36 


9 


26 


8 


79 


2370 


33 


35 


10 


27 


8 


80 


2640 


36 


35 


10 


27 


8 


80 


2880 


39 


35 


10 


27 


8 


80 


3120 


42 


34 


9 


27 


8 


78 


3275 


45 


34 


7 


26 


7 


74 


3330 


48 


33 


5 


22 


7 


67 


3215 


51 


32 


3 


21 


6 


62 


3160 


54 


31 





18 


5 


54 


2915 


60 


25 





15 


4 


44 


2640 


(Adult) 















1 Kilo = 2.2 pounds. 

As regards abnormal babies, very fat babies need fewer calories 
than very thin ones; in general, the thinner the baby, the more 



74 PRACTICAL INFANT FEEDING 

calories he needs. A very thin baby may need an energy 
quotient as high as 160 before he can begin to gain weight, and 
underweight babies in general, of whatever class, always need 
more than those of normal weight. 

According to Dennett^ the average needs of bottle-fed babies 
are as follows: 

Fat infants over four months of age 40 to 45 calories per pound per day. 

Average infants under four months of 

age, and moderately thin babies of 

any age 50 to 55 calories per pound per day. 

Emaciated infants 60 to 65 calories per pound per day. 

Ladd^ found in a large series of poorly nourished infants 
that most of them did not make satisfactory gains in weight 
until the energy quotient was raised to 140 to 160, and some- 
times as high as 175 or 190. 

The practical conclusion to be drawn from all these figures is 
that theoretic caloric requirements are only a rough guide in 
the practical feeding of undernourished babies, and that the 
food must be pushed to the very limit of tolerance, irrespective 
of calories, until the baby begins to gain weight. 

1 Infant Feeding, 1920, p. 70. 
^2 Arch. Ped., vol. xxix, No. 5, 1912. 



CHAPTER n 

THE STOOLS IN INFANCY 

A KNOWLEDGE of how to interpret the stools is of the utmost 
importance in practical infant feeding, and the intelligent 
pediatrician should be able to reason backward from data ob- 
tained by stool examination, so that he can tell fairly accurately 
what processes are going on in the baby's intestine. The macro- 
scopic examination is the most important, but in many cases 
microscopic examination also adds valuable data. While stool 
examination is important, the characteristics of the stools must 
not be taken by themselves in determining what to feed any 
given case, but must be considered in relation to the gain in 
weight, general condition of the baby, history, etc. 

Let us take up the discussion of stools in the following order: 

1. General characteristics. 

2. Fat in the stools — its amount, form, and significance. 

3. Sugar and starch. 

4. Protein. 

5. Miscellaneous. 

General Characteristics. — Number per Day. — ^The number of 
stools passed in twenty-four hours varies considerably with the 
individual baby and the sort of food that he is taking. The 
average breast-fed baby has, as a rule, more stools than the 
normal bottle-fed baby. The breast baby has ordinarily from 
one to three stools a day, but in certain cases may have as many 
as six or seven and still do perfectly well. This would be im- 
possible in a bottle baby. The number of stools a normal bottle- 
fed baby has depends a good deal upon what sort of food he is 
taking. If he is taking a formula containing a good deal of mal- 
tose he will have usually three or four stools a day, or the same 
number may result if he is taking a food high in sugar and fat 

75 



76 PRACTICAL INFANT FEEDING 

and low in protein. This is due to the stimulating action of the 
fatty acids formed from sugar and fat decomposition on intes- 
tinal peristalsis. If a food low in sugar and high in protein is 
fed the number of stools will be considerably diminished, and he 
will have only one or two a day, or one every other day. Bottle- 
fed babies ordinarily have fewer stools than those fed on the 
breast because breast milk contains so much more sugar and fat 
than most cow's milk modifications do, and, moreover, the 
casein and calcium of cow's milk tend to be constipating. If 
there is anything irritating in the intestine, increased peristalsis 
and an increased number of stools result. This may be brought 
about by nervous influences, but almost always is due to un- 
digested or fermented food products or to actual infection of the 
intestinal wall by bacteria. 

In general, it may be said that any number of stools over 
four per day is abnormal for a bottle-fed baby. 

Form and Consistency. — ^The stools of a breast baby are rarely 
formed, and resemble thick porridge in consistency. They are 
rarely smooth, and may normally contain small white fat curds 
and small amounts of mucus. The normal stools of a bottle-fed 
baby are usually formed and are smooth and homogeneous; 
they should contain no curds, and none but the very smallest 
quantity of mucus. They may vary a great deal in consistency; 
in, general, those babies who are fed on high casein and low sugar 
will have rather hard, dry stools, while those on high sugar and 
fat feeding are likely to have softer stools, which are not so well 
formed as those of the former type. If the baby's absorptive 
power is very good and if he is thus absorbing most of the food 
he takes in, the stools may have to stay in the colon and rectum 
for a considerable period of time before enough is collected to be 
evacuated; therefore the stool becomes hard and scybalous from 
loss of water. Skimmed milk and buttermilk stools are usually 
very smooth and shiny when spread out with a throat stick; if 
fat is added, they remain smooth, but lose their shiny character. 

Odor. — ^The stools of babies fed on a milk diet rarely are very 
offensive. Those of the breast-fed baby have an aromatic acid 



THE STOOLS IN INFANCY 77 

odor, while those of the bottle baby usually have a cheesy, 
slightly foul odor. If a high sugar and fat is fed, however, the 
odor is likely to be slightly acid, even in the normal bottle baby. 
With sugar and fat fermentation the odor is always acid (acetic 
and butyric acids), with a diarrhea caused by protein putrefac- 
tion the odor is foul. If the baby is being fed a large amount of 
starch which he is not digesting well, and which is fermenting in 
his intestine, the odor may be very offensive, like that of a pig- 
pen. The odor of ammonia is often noticed in connection with 
high protein stools, but may in a good many cases be due actually 
to ammonia on the diaper from an alkaline, concentrated urine, 
rather than to the stool. 

Color.— The color of the breast baby's stool is golden yellow, 
or may sometimes normally be greenish. The color of a bottle 
baby's stool depends upon what sort of food he is being fed, and 
whether or not he has indigestion. 

The color is usually a rather light yellow or yellowish brown. 
If a considerable amount of fat is fed it will be lighter, and if 
high fats plus high sugars are fed it is likely to be a brighter yel- 
low. With high fat and casein and low sugar it is grayish, some- 
times almost white. Skimmed milk mixtures high in protein 
give a stool of light gray or grayish-brown color, of smooth shiny 
consistency when smoothed out with a throat stick. 

The stools of diarrhea due to protein putrefaction are brown. 
Adding a malt soup preparation to the diet gives a brown color 
similar to that of the original malt soup; starch in the diet also 
tends to cause a brownish color. Beef juice if added to the diet 
in sufficient quantities gives a dark brown color. Bismuth and 
iron give a grayish-black color. Argyrol when put in a baby's 
nose usually comes out in the stools unchanged in color and may 
cause a good deal of worry to the mother. Blood coming from 
the stomach gives a rich dark black color (tarry stool), while 
blood from the intestine gives a dark brick-red color if digested, 
or if not digested may appear in small bright red streaks. Blood 
on the outside of a constipated stool usually simply means that 
the rectum has been irritated somewhat by the progress of the 



78 PRACTICAL INFANT FEEDING 

hard stool. Green is the most common abnormal color, and is 
seen in cases where there is fat, or more particularly sugar fer- 
mentation going on. A stool which is yellow when passed, but 
which turns green on standing in the air, is not abnormal. The 
green color is caused by the oxidization in the air of the bile- 
pigments. Stools which are green when passed are always ab- 
normal. The explanation of the green color so commonly seen 
is as follows (Hecht) ; 

Normally in stools there is hydrobilirubin (from the bile- 
pigments). This arises from bilirubin by reduction under the 
influence of intestinal decomposition, from the ileocecal valve 
onward. If the reduction processes are particularly active then 
the reduction of hydrobilirubin follows still a step further, to the 
colorless leukohydrobilirubin. If peristalsis is increased, so that 
there is no time for reduction, then the oxidation product of bili- 
rubin (green biliverdin) is found in the stool. 

Reaction. — The reaction of the stools is of great practical 
importance in infant feeding. As we have said before several 
times, there are always two opposing processes going on in the 
infant's intestine — fermentation of carbohydrate and putrefac- 
tion of protein. The breaking down of carbohydrate gives rise 
to acid end-products, with acid intestinal contents; the breaking 
down of protein gives alkaline end-products. There should be 
in the normal baby's intestine a certain balance between the 
two — that is, there should not be excessive fermentation or ex- 
cessive putrefaction. Any baby fed on a milk containing a large 
amount of protein and but little carbohydrate will have alkaline 
stools, any baby fed on a high fat and sugar with little protein 
will have acid stools. Both of these conditions are normal, pro- 
vided, however, that the alkalinity or acidity does not reach an 
excessive degree. If too much fermentation of carbohydrate or 
fat or too much putrefaction of protein takes place, the reaction 
becomes too acid or alkaline and trouble in the form of diarrhea 
results, due to too great a concentration of irritating alkaline or 
acid end-products. Excessively acid stools of abnormal con- 
sistency and appearance mean, then, that sugar or possibly fat 



THE STOOLS IN INFANCY 79 

is not being taken care of; excessively alkaline stools mean that 
protein is being putrefied. In a few cases of sugar fermentation 
where there is a great deal of mucus present it may be possible 
to have neutral or alkaline stools, owing to the fact that the 
decomposition products of mucus are alkaline in character and 
may neutralize the original acidity. The breast baby has, it is 
true, very acid stools, of a degree of acidity which would be 
quite abnormal for the bottle baby. The probable reason why 
this excess acidity does not harm the breast baby is that it is 
mostly in the large intestine, whereas in the bottle-fed baby the 
excess acidity is usually in the small intestine where the deli- 
cately adjusted digestive processes are taking place. What 
bearing has all this on practical infant feeding? A good deal. 
If a strongly acid, normal appearing stool is seen, it means that 
it is not safe to add any more sugar to the diet, and if anything 
is added it should be protein or possibly starch, as the acidity 
shows that the baby is approaching the limit of his sugar toler- 
ance. If an abnormal appearing, strongly acid stool is seen, it 
means that the limit of sugar tolerance has been exceeded, and 
that the sugar in the diet must be reduced or a change must be 
made to a sugar which does not ferment so easily. 

The normal appearing, alkaline stool is the type that we like 
to see. This tells us that there is a mild putrefaction going on in 
the intestine (the normal condition when cow's milk is fed) and 
that if for any reason we desire to add sugar to the diet it is 
perfectly safe to do so, as the stool is alkaHne, and there is a wide 
margin of safety. An abnormal appearing alkaline stool means 
that too much protein is being decomposed, and a decrease in the 
amount of protein and increase in the sugar is indicated. 

These conceptions help me a great deal every day in my 
practical feeding work. The foregoing can perhaps be more 
clearly expressed in the form of a diagram. 

Alkaline Neutral Acid. 
/ z 3 

X 1 1 1 Y 



Fig. 1. 



8o PRACTICAL INFANT FEEDING 

The reaction of the normal stool is at 1, 2, or 3, and if the 
amount of acid or alkaline decomposition products in the in- 
testine does not get too far away from the neutral point, over 
to the extreme limits of X and Y, the baby gets along well; if 
the reaction becomes excessively acid or alkaline, he gets into 
trouble. 

The reaction is easily determined by little pieces of red or 
of blue litmus-paper, or, after a certain amount of practice, by 
the smell of the stool. 

Fat in the Stools (See Section on Metabolism of Fat). — ^A 
considerable amount of fat occurs in the stools normally, and in 
cases of fat indigestion this may be markedly increased. 

(a) Macroscopic Examination. — The macroscopic appear- 
ance of the stools is often suggestive of an excessive fat con- 
tent. Stools of four different sorts containing an excess of fat 
may be seen. 

The Soapy Stool. — ^This is a large, dry, crumbly, light 
colored stool, which contains a large excess of insoluble calcium 
soaps. Its reaction is usually alkaline, and it is seen in babies 
who are being fed on a fairly high fat, low sugar, and high pro- 
tein. It is evidence of fat fed in improper relationship to the 
other food elements, rather than of a disturbance caused by fat 
per se. 

The "Scrambled Egg" Stool. — ^This stool is loose, of the 
consistency of thin scrambled eggs, and is strongly acid in reac- 
tion. It contains many small white, fat curds, and usually ex- 
coriates the buttocks, due to excessive acidity. It contains a 
large amount of fat partly in the form of soaps, but especially 
as fatty acids. It is usually seen in babies who are being fed on 
a high sugar and fat diet. 

The Oily Stool. — This stool is usually bright yellow or 
sometimes yellowish-gray in color. It looks greasy, and if 
placed on a piece of paper leaves a transparent oil stain. It is 
usually of the consistency of thick commeal mush, and contains 
a large excess of neutral fat and fatty acid. The occurrence of 
this type of stool means almost always that the baby is being 



THE STOOLS IN INFANCY 8 1 

grossly overfed with fat, and more neutral fat (entirely undi- 
gested) is seen in it than in any other type of stool except those 
of severe diarrhea. There may be only two to four of these 
stools a day, or they may be more frequent (six to seven) and very 
loose (fat diarrhea). 

The Normal Appearing Stool. — ^An excess of fat may be 
present in a stool which appears normal macroscopically, and is 
revealed only by the microscope. 

Microscopic Examination. — ^The microscopic examination of 
the stools for fat is of value if interpreted correctly, but may 
lead to entirely erroneous conclusions if it is not. The usual 
mistake that beginners make is to disregard the clinical appear- 
ance of the baby, his weight and his well being, and to rush to 
the laboratory with a stool. If they see a little fat under the 
microscope, they immediately make a diagnosis of ''fat indiges- 
tion," cut down or omit entirely the fat in the diet, and thus 
deprive the baby often unnecessarily of many valuable calories. 
This has led many men astray, and under such circumstances 
microscopic examination of the stools for fat does more harm 
than good. It must he remembered that there is always in the 
normal stools of all babies faking any fat in their milk a consider- 
able amount of fat. According to Holt, Courtney, and Fales the 
dried stools of normal breast-fed babies contain on the average 
about 35 per cent, of fat, in bottle-fed babies 36 per cent.^ The 
fat in the stools is in the form of neutral fat, fatty acids, and 
soaps; mostly soaps. Fatty acids and soaps represent fat which 
has been digested, but not absorbed, neutral fat represents fat 
which has not even been digested. 

There are methods of microscopic stool examination which 
attempt to distinguish between all these three constituents and 
to determine approximately how much of each one of these is 
present. It is this which has created so much confusion in the 
minds of students, but from a clinical point of view is entirely 
unimportant and cannot be done accurately anyhow. What is 
important to determine is whether or not there is an excess of 
1 Amer. Jour. Dis. Chil., vol. 17, April and June, 1919. 



82 PRACTICAL INFANT FEEDING 

neutral fat and of total fat (neutral fat, fatty acids, and soaps 
together). This is done as follows: 

First Procedure.— A small portion of the stool is rubbed 
up with a little water on a glass slide until a thin, smooth paste 
is formed. A drop or two of an alcoholic solution of "soudan 
III" stain is then mixed with this, and the film spread thin so 
that the Hght will shine through it. The preparation is then 
examined under the microscope with the low power. Neutral 
fat stains in bright orange-red globules. It is abnormal for more^ 
than a very few stained globules to appear with this first pro-' 
cedure, and shows that an abnormal amount of fat is coming 
through entirely unsplit. It is not at all common to see any 
neutral fat in a stool unless it is a diarrheal one, as usually most 
of the excess fat is in the form of fatty acids and soaps. Neutral 
fat is seen especially in the stools of babies who are being grossly 
overfed with fat, or in diarrheal stools, where the intestinal con- 
tents has been hurried through so quickly that the fat has not 
had a chance to be split. 

Second Procedure. — ^A drop or two of glacial acetic acid is 
added to the first preparation and mixed thoroughly with it. 
Then the slide is heated for a moment over the Bunsen burner. 
In this procedure the heat and acetic acid break down the soap 
and neutral fat which are present into fatty acid; this fatty 
acid when melted is in the form of globules, and takes the stain 
in the same way that the neutral fat did originally. Any fatty 
acid which may have been originally present is also melted, and 
takes the stain. By microscopic examination of the preparation 
after this second procedure a rough idea of the total fat content 
may thus be obtained. There are so many factors that enter 
into the composition of a stool that it is impossible to have any 
absolute standard for what is an excess and what is not. In the 
first place, a dry, concentrated stool is likely to contain more 
fat than one of thinner consistency, which contains more water. 
Also, practically always when there is a diarrhea of any sort 
there is likely to be a large amount of fat in the stool, owing to 
the fact that the increased intestinal peristalsis sweeps out 



THE STOOLS IN INFANCY 83 

neutral fat, fatty acids, and soaps before they have had a chance 
to be digested or absorbed. So excess fat in a stool does not 
necessarily mean a primary fat indigestion. Again, if a baby 
were having only one stool a day of moderate size, his fat absorp- 
tion might be quite normal even if the stool when examined 
microscopically showed a large amount of fat, whereas if there 
were three or four large stools a day containing the same pro- 
portion of fat, the fat absorption would be considerably de- 
creased, and a fat indigestion would be indicated. Furthermore, 
as Grover^ has pointed out, if a large amount of protein is being 
fed, and there is consequently in the stool a considerable protein 
residue, there will not appear to be as much fat in the stool as 
in one where less protein residue is present. 

From a practical point of view the fat content of stools as 
determined by this method may be divided into three groups: 

1. In almost any normal stool, after Procedure II, there will 
be seen a good many fat globules scattered through the micro- 
scopic field. These do not run together much, and it is obvious 
that most of the stool consists of something else than fat. This 
is normal, and does not indicate that any reduction of fat in the 
diet is necessary. 

2. There is a larger amount of fat in the stool than there is 
in the stools of Group I, and the stained globules are scattered 
very thickly through the microscopic field. If the baby is doing 
well and gaining weight, without symptoms of indigestion, such 
a stool picture does not call for any interference. If the baby is 
not doing well, it is best to reduce the amount of fat in his diet. 

3. In the third group after Procedure II almost the whole 
stool seems to turn to melted fat globules, and under the micro- 
scope they are crowded together so thickly that they take up 
the entire field. Such an excess as this is usually seen in hard, 
dry, crumbly, light colored, "soapy" stools, or in oily, greasy 
stools, and practically always means that a reduction of the fat 
intake is indicated. 

The only possible way that anyone can learn to interpret the 
1 Jour. Amer. Med. Assoc, vol. 6, No. 6, February 5, 1921. 



84 PRACTICAL INFANT FEEDING 

fat content of stools is by examining a great many of them, and 
by comparing their content in fat carefully with the condition 
of the baby, the composition of his food, and the macroscopic 
character of the stool. The procedure is an art rather than an 
exact science, and each individual after practice establishes his 
own standards. Properly used, it gives information of con- 
siderable value in handling the case. 

Older Children. — ^With older children on a mixed diet there is 
not so much fat in the stools as there is with smaller babies; 
therefore what might be quite normal for a baby would be ab- 
normal for a child of two or three years. A considerable amount 
of fat in the stools is, therefore, of more importance in the case 
of an older child than it is in a baby. Babies under two months 
old almost always have a large amount of fat in the stools, even 
if they are doing well. 

Sugar and Starch. — Sugar. — The stools of a baby who is 
utilizing sugar normally contain no sugar, as the absorption is 
nearly 100 per cent. If for any reason the absorption is poor, 
the unabsorbed sugar undergoes fermentation, and the acids 
which have been formed appear in the stools, giving the char- 
acteristic sour smell and acid reaction. In a very few cases 
unaltered sugar may be demonstrated in the stools, but this is 
by no means usually the case, and most investigators have re- 
ported negative findings. We do not, therefore, test directly for 
sugar in the stools, but depend upon the recognition of its de- 
composition products to determine whether or not it is being 
well utilized. It is probably not possible to have sugar indiges- 
tion without some sugar fermentation, and the type of stool 
depends largely upon the amount of undigested sugar that is 
being fermented. The stools of mild sugar indigestion are loose 
in consistency, usually yellowish-green in color, in number three 
or four per day, smelling strongly of acetic acid, and containing 
a good many small fat curds. They react strongly acid to 
litmus. In more severe sugar indigestion they are more fre- 
quent, watery, of a light or dark green color, strongly acid in 
reaction, and usually contain a good deal of mucus. They also 



THE STOOLS IN INFANCY 85 

may contain fat curds or even casein curds, which have been 
hurried through the intestine too fast to be absorbed. Micro- 
scopic examination for fat in stools such as this is of no value, 
as they always contain large quantities of fat if the baby is tak- 
ing an appreciable amount in his food. The macroscopic appear- 
ance, the smell, and the reaction are the important things to 
consider in the stools of sugar indigestion. 

Starch. — ^Normally, there is only a very small amount of 
starch in the stool. 

Starchy stools may be of two types: 

The Fermented Starch Stool. — This is the most common 
type of stool seen in starch indigestion. It is large in size, of 
mushy consistency, of very offensive odor, either foul or resem- 
bling the sour smell of a pigpen. The end-products of starch 
fermentation are acid in reaction, but the reaction of these 
stools may be either acid or alkaline, depending upon the degree 
of fermentation, the amoimt of mucus present, and the amount 
of protein food which is being taken. These last two factors tend 
to give an alkaline reaction. These stools are usually olive green 
or brownish in color, are not homogeneous, and usually contain 
many small macroscopic masses of undigested starch and cel- 
lulose, which may be of a mucilaginous consistency. 

Microscopically they show a large amount of undigested 
starch, either in the form of broken up granules or whole starch 
globules. Also many large iodophilic bacteria and yeasts are 
likely to be seen in any starchy stool. 

The Unfermented Starch Stool. — ^In the fermented starch 
stool there has been a poor digestion of starch, and the undi- 
gested residue has undergone fermentation, with the production 
of irritating and offensively smelling substances. In the unfer- 
mented starchy stool there has been, it is true, an inadequate 
digestion and absorption of starch, but the unabsorbed residue 
has not fermented. These stools are large in size, usually brown 
in color, alkaline, rather smooth in consistency, of moderately 
foul odor, and have much the appearance of normal stools. 
Microscopically, however, they show a large amount of undigested 



86 PRACTICAL INFANT FEEDING 

starch, which would never have been expected were it not for 
the microscopic examination. The children with this type of 
stool may seem well, and may show no symptoms of indigestion. 
It is probable that if fermentation does not take place the 
presence of undigested starch does little actual harm, but it is 
an indication that the amount of starch taken is more than the 
child can digest, and there is no telling when it may start to 
ferment and do him considerable harm. 

Technic of Microscopic Examination for Starch. — To a small 
portion of stool rubbed up with a little water on a glass slide a 
drop or two of Lugol's solution is added (iodin 2, KI. 14, water 
100). If there is much starch present this turns a dark blue or 
black color, and when examined under the microscope many 
black masses of undigested starch are seen. If the starchy part 
of the food intake has been thoroughly cooked the starch in the 
stool will appear as small masses of irregular shape and size; 
if the food has not been thoroughly cooked so that the starch 
granules have not been broken down, characteristic round or 
oval unbroken starch granules are seen. Different sorts of 
starches have different granules, and by careful examination one 
may often determine exactly what kind of starch is not being 
digested (oatmeal, barley, vegetable starch, etc.). Granules or 
masses which stain a purplish-red color represent starch which 
has been partly dextrinized by the processes of digestion. Un- 
digested cellulose does not take the blue color with Lugol's solu- 
tion, but is stained a light brown. If it has been partly broken 
down by the intestinal bacteria, which is often the case, it stains 
a light blue or a violet. 

Protein. — ^As we have said before, the feeding of a high pro- 
tein percentage in connection with a low fat and sugar produces, 
if the protein is well digested, a smooth, yellowish-brown or 
grayish-brown, alkaline stool, of rather cheesy odor. This ap- 
pears shiny and glistening when smoothed out with a throat 
stick. Lactic acid, buttermilk, and skimmed milk stools are of 
this type, and are called normal "high protein" stools. Abnor- 
mal protein stools may be divided into two groups: 



THE STOOLS IN INFANCY 87 

Those with casein curds. 

Those in which there is excessive putrefaction of protein. 

Casein curds are small, smooth, bean-shaped, yellowish-white 
masses. They range from the size of an ordinary baked bean to 
that of a large lima bean. They are tough and leathery in con- 
sistency, sink in water, and do not dissolve in ether. They can 
be confused with nothing else after one has once become familiar 
with their appearance. They do not look anything like fat 
curds, and if one has once seen a fat and a casein curd side by 
side he will never have any difficulty in distinguishing them 
thereafter. Casein curds do not ordinarily occur in the stools if 
anything has been done to the milk to modify the coagulation of 
casein, such as the addition of an alkali, boiling, peptonization, 
or treating with the lactic acid bacillus. Undigested casein may 
also sometimes appear as small indeterminate brownish-yellow 
masses of thick, gluey consistency. The exact significance of 
casein curds is in some dispute. A stool which contains them 
certainly cannot be considered normal, but it is a question 
whether they do much harm or represent a severe digestive dis- 
turbance. They act more as foreign bodies than in any other 
way, and represent a non-digestion of a certain portion of casein, 
without the addition of any bacterial decomposition. They may 
occur in stools of almost any color or consistency. 

Putrefaction of Protein. — If there is an excessive putrefaction 
of protein in the intestine the stools become increased in num- 
ber, loose in consistency, brownish in color, foul in odor, and 
alkaHne in reaction. This type of stool is quite different usually 
from the casein curd stool ; in the former we have a non-digestion 
of casein, without any extensive bacterial putrefaction; in the 
latter we have a non-digestion of protein with added bacterial 
putrefaction. Such stools as this usually indicate a more severe 
disturbance of digestion than do those of the first type. 

Miscellaneous. — The Starvation Stool. — ^This type of stool 
occurs when the baby is being actually starved or is taking a 
weak cereal water preparation. It naturally contains very 
little food residue, and is made up of intestinal secretions, bac- 



88 PRACTICAL INFANT FEEDING 

teria, mucus, and bile. It is usually alkaline in reaction, rather 
dark brown or greenish-brown in color, foul in smell, and sticky 
and loose in consistency. A common mistake is to confuse it 
with the stools of indigestion, and to continue the starvation, 
when, in reality, more food is needed. 

Test For the Gas Bacillus. — Most of the procedures involved 
in bacteriologic examination of the stools are too complicated 
for clinical use. There is one organism, however, which may be 
of considerable importance in diarrheal diseases and in chronic 
indigestions. This is the gas bacillus, the significance of which 
has caused a good deal of controversy. It is true that it may 
occur in the stools of normal babies; it is also true that it some- 
times occurs in the stools of babies with diarrhea, and seems to 
be the cause of the disturbance, as the diarrhea improves as soon 
as the gas bacillus infection has been overcome, usually by the 
employment of a milk containing large numbers of lactic acid 
bacilli, which are directly antagonistic to the gas bacillus. 

The technic of the gas bacillus test used at the Children's 
Hospital is as follows: 

1. Fill a U-shaped fermentation tube and a test-tube with 
concentrated nitric acid, let stand three minutes, and empty out 
the nitric acid. 

2. Rinse both tubes with hot tap-water until neutral to 
litmus-paper. 

3. Place a small bit of stool, about a gram of dextrimal- 
tose, and about 15 c.c. of hot tap-water in the test-tube, and 
boil vigorously for half a minute. 

4. Put the contents of the test-tube iQto the fermentation 
tube, taking care that it is filled up to the top, and that no air- 
bubbles remain in it. 

5. Plug the tube with flamed cotton and incubate for twenty- 
four hours. 

Gas in the top of the tube indicates that the gas bacillus is 
present in greater or lesser munbers, depending upon the amount 
of gas present. Less than one inch of gas in the tube is prob- 
ably of no significance. 



THE STOOLS IN INTANCY 89 

Bile. — It is occasionally of importance to test for bile in the 
stool. Rub up a small portion of stool in a mortar or evaporating 
dish, with a concentrated solution of corrosive sublimate, and let 
it stand for three hours. A brick-red color indicates that bile is 
present. 



CHAPTER III 

HUMAN MILK 

Colostrum. — The breast does not begin to secrete milk im- 
mediately after parturition. For the first few days there is a 
scanty secretion of a slimy, yellowish fluid — the colostrum. The 
amount of colostrum is not large, the following figures being 
given by Von Jaschke:^ 

First day, 2 c.c. 

Second day, 6 c.c. 

Third day, 10 c.c. 

The composition of colostrum seems to vary considerably 
according to the figures given by various observers: 

Fat. ' Sugar. Protein. Salts. 

Holt, Courtney, and Fales^ 2.83 7.59 2.25 0.30 

Pfeiffer^ 2.17 3.5 6.45 0.34 

Adriance^. . . 3.77 5.39 3.31 0.27 

It is certain, despite the rather wide variations in the above 
table, that it is relatively low in fat and sugar, and high in 
protein and salts. A considerable amount of the protein is in 
the form of globulin, which causes colostrum to coagulate when 
heated. 

According to Courtney the composition of the ash as con- 
trasted with the ash of mature milk is as follows: 

Total ash, CaO. MgO. P2O6. N02O. H2O. CI. 
per cent. 

Colostrum 0.30 0.044 0.010 0.041 0.045 0.093 0.056 

Mature milk 0.20 0.045 0.007 0.034 0.034 0.060 0.035 

iZtschr. f. Kinderh., vol. 16, June, 1911. 
2 Amer. Jour. Dis. Chil., vol. 10, No. 4, 1915. 
^ Czerny and Keller, Des Kindes Ernahrung, Leipzig, 1906. 
90 



HUMAN MILK 9 1 

Colostrum is especially characterized by containing numer- 
ous large leukocyte-like bodies, the ' 'colostrum corpuscles," 
which contain many fat-droplets within the protoplasm, and 
which give to the colostrum its characteristic yellow color. The 
smaller corpuscles are probably leukocytes, according to Czerny, 
the larger ones large mononuclear cells. They may appear in 
mature milk if for any reason nursing has been interrupted, milk 
is allowed to collect in the breast, and there is consequently a 
diminished milk secretion. They disappear again as soon as 
nursing is resumed. 

"Coming In" of the Milk. — The true breast milk "comes in" 
usually anywhere from forty-eight to ninety-six hours post- 
partum, but in some cases may be delayed considerably longer. 
It may come in gradually, so that the mother does not notice it, 
or it may, on the other hand, come in more suddenly, so that she 
can feel her breasts filling hour by hour. 

Dluski,^ in 326 primipar^, found that the time of coming in 
of the milk was as follows : 

9 times, 24 to 48 hours. 

115 times, 48 to 72 hours. 

159 times, 72 to 96 hours. 

42 times, 96 to 120 hours. 

1 time, 120 to 144 hours. 

Physical Properties of Human Milk. — The specific gravity is 
from 1030 to 1032. The color is similar to that of cow's milk; 
the taste is a little sweeter, owing to the larger amount of milk- 
sugar that it contains. In certain cases the colostrum may be 
much more yellow than usual, and this yellow color may per- 
sist for a considerable period after the colostrum stage has 
passed. Very yellow milks of this nature do not ordinarily agree 
with babies, and in the few cases of mothers with bright yellow 
milk that I have seen the baby has usually been troubled a good 
deal with vomiting. The pigment is contained in the fat, accord- 

^ These de Paris, 1894 (quoted by Morse and Talbot, Diseases of Nutri- 
tion, etc.). 



92 PRACTICAL INFANT FEEDING 

ing to Palmer and Eckles/ and is tlie same pigment that there is in 
normal colostrum except that it is present in a more concen- 
trated form. It consists of a mixture of carotin and xantho- 
phyll, and is closely allied to vegetable carotin. It is derived 
especially from the chlorophyll in green vegetables, but may 
also be present in such vegetables as carrots, beets, and yellow 
corn. It is well, therefore, in any case where the milk is much 
more yellow than normal, and seems to upset the baby, to omit 
all green fruits and vegetables from the diet for a few days. It 
is in the first few weeks of lactation that this excessive yellow 
pigmentation is most likely to be observed. 

Amount. — ^Nature has apparently not intended that the 
infant should receive much food in the first few days, therefore 
the amount of milk produced during the first week is not large. 
It increases gradually up to a certain point, as the baby's diges- 
tive powers develop, and then the amount remains more or less 
stationary during the rest of lactation. 

The following table, by von Jaschke,^. shows the amount of 
breast milk that a normal breast-fed baby received on various 
days during the period of lactation: 



Colostrum 
period 



Day. Amount. 

First 2.5 c.c. 

Second 6.0 c.c. 

Third 10. 5 c.c. 

Fourth 19. 5 c.c. 

Fifth 300 c.c. 

Sixth 360 c.c. 

Seventh 440 c.c. 

Fifteenth 570 c.c. 

Twentieth 720 c.c. 

Thirty-seventh 805 c.c. 

Seventy-second 825 c.c. 

Eighty-seventh 925 c.c. 

Ninety-second 950 c.c. 



By putting several babies to the breast, and thus furnishing 
a considerable extra stimulus, it is possible sometimes to greatly 



1 Jour. Biol. Chem., vol. xvii, 1914. 

2 Loc. cit. 



HXJMAN MILK 93 

increase the amount of milk. Sommerfeld^ cites a wet-nurse of 
Finkelstein's whose daily average in the twenty-fifth month of 
lactation was 1700 ex., and cases are on record where as much 
as 3 liters a day have been produced over a considerable period 
of time. The amount of milk produced is ordinarily between 
one-sixth and one-quarter the weight of the baby after lactation 
has become well established. The amount taken at each feeding 
varies a good deal, but the twenty-four-hour quantity remains 
fairly constant. According to EngeP the largest amount is 
always given at the first feeding in the morning, and tends to 
decrease as the day progresses. It is a commonly observed fact 
that in many cases when the supply of milk is not enough for 
the baby, this scantiness shows itself first by signs of hunger on 
the part of the baby after the 6 or 9 p. m. feeding. 

Galactogogues. — "An artificial enrichment of milk secretion 
is not possible, and can be brought about by no drug or prepara- 
tion, no matter what name it may bear, no matter what recom- 
mendation it may hold" (Engel). 

If there is one thing that pediatricians are agreed upon it 
is that there is no practical, satisfactory galactogogue, and that 
the best way of increasing milk production is by stimulation of 
the breast by vigorous and frequent nursing. Especially is it 
necessary, in order to have abundant milk production, that the 
breast be completely emptied at each feeding. It has been said 
that pituitrin increases the flow of milk; this increase is only 
temporary, however, and is followed later by a diminution. 
Cornell^ in 1918 carried on an interesting series of observations 
with placental extract. To 100 mothers, just delivered, he fed 
5 grains of a preparation of placental extract four times a day for 
three days. He observed also 70 control cases to whom no pla- 
cental extract was given. He found that 87 per cent, of the 
babies whose mothers received placental extract began to gain 
on the fourth and fifth days, as against 69 per cent, whose 
mothers did not receive it. Also, 44 per cent, of the babies 

1 Handbuch der Milchkunde, Wiesbaden, 1909. 

2 Ibid. ^ Surg., Gyn., and Obstet., vol. xxvii, 1918. 



94 PRACTICAL INFANT FEEDING 

whose mothers received it regained their birth weights before 
leaving the hospital, as against 24 per cent, of those whose moth- 
ers did not receive it. Such a piece of work is suggestive, but at 
the present time it is fair to say that we have no proved galac- 
togogue. 

The repute that malt liquor enjoys as a galactogogue is prob- 
ably due more to the increased amount of fluid ingested than to 
any specific property. 

Chemical Composition. — The reaction of human milk is 
amphoteric; acid to phenolphthalein, alkaline to litmus. The 
reason for this amphoteric reaction is that it contains both 
mono- and diphosphates. The first react as weak acids (acid to 
phenolphthalein), the latter as bases (alkaline to litmus). 

The milk of all mammals contains the following substances 
in an aqueous medium: 

Fat — In emulsion. 

Casein and lactoglobulin — in suspension. 

Lactalbumin 



Sugar 

Salts 

Extractives 



, in solution. 

Salts 



The composition of human milk is usually given as 

Fat. . , 4. GO per cent. 

Sugar 7 . 00 per cent. 

Protein 1. 25 per cent. 

Salts 0. 20 per cent. 

The variations may be considerable, however, in the milks- 

of different women, and a baby may thrive on a milk which is 

far different from the average composition. According to 

Schlossmann,^ the variations may be within the following wide 

limits : 

Fat 1. 65— 9.46 per cent. 

Sugar 5.2 —10. 9 per cent. 

Protein 0. 56 — 3 , 4 per cent. 

1 Ztschr. f. Physiol. Chemie, Bd. xxii, p. 5197. 



HUMAN MILK 95 

Fat. — The fat is the one most likely to vary of all the food 
elements, and very high or very low percentages are not un- 
common. Low fat precentages are often found in combination 
with high protein percentages. There does not seem to be any 
relation between the stage of lactation and the amount of fat 
present. There is much less fat in the milk at the beginning of a 
nursing (fore-milk) than at the end (strippings) . The extreme 
variations in this respect observed by Denis and Talbot^ were 
0.66 per cent, fat in the first part of the nursing and 10 per cent, 
in the last part. There is usually, however, less than 4 per cent, 
difference, as can be seen from the figures below, taken from 
their table: 

Fore-milk. Strippings. 

Case 1 — 4.0 per cent. fat. 8.0 per cent, fat 

Case 2 — 6.4 per cent, fat 16.0 per cent, fat 

Case 3 — 2 . 4 per cent, fat 8.0 per cent, fat 

Case 4 — 2.4 per cent, fat 3 . 8 per cent, fat 

Case 5 — 2.5 per cent, fat 4.4 per cent, fat 

Case 6 — 3.2 per cent, fat 6.6 per cent, fat 

Case 7 — 1.5 per cent, fat 2.9 per cent, fat 

Case 8 — 0.66 per cent, fat 10.0 per cent, fat 

Sugar. — The average amount of lactose in 60 samples of 
milk examined by Talbot and Denis was 7.19 per cent. There 
is less variation of the lactose content than is the case with 
either the fat or protein. There is a general tendency for the 
concentration of lactose to increase throughout the period of 
lactation. During the first ten weeks of lactation two-thirds 
of the samples examined by Talbot and Denis contained less 
than 7 per cent. After the tenth week there were many samples 
containing as high as 8 per cent. The smallest percentage 
of lactose found after the colostrum period was 5.49 per cent.; 
the highest, 8.35 per cent. 

Chemically the lactose in human milk is identical with that 
in cow's milk. 

Protein. — ^According to Engel the protein in human milk 
averages 1.04 per cent., according to Courtney, 1.15 per cent., 

1 Amer. Jour. Dis. Chil., vol. 18, No. 2, 1919. 



96 PRACTICAL INFANT FEEDING 

according to Denis and Talbot it is usually over 1.5 per cent, 
up to the fourth week, and after the twelfth week averages 
below 1.2 per cent. There is a tendency for it to become low 
late in lactation, and it may be 1 per cent, or lower from the 
tenth month onward. The amount of protein in the fore-milk 
and strippings varies but little. The proteins of human milk 
fall into two groups: 

1. Casein. 

2. Lactalbumin and lactoglobulin. 

Casein is a water-insoluble, phosphorus-containing protein. 
It is held in suspension in milk on account of its combination 
with calciimi and on account of the reaction of the milk. If 
human milk is acidified or treated with rennin the casein is 
precipitated in fine delicate flakes. 

Lactalbumin and lactoglobulin are water-soluble proteins 
which coagulate on heating. There has been a good deal of dis- 
cussion as to the relative amounts of casein and lactalbumin (plus 
globulin) in human milk. According to most authorities the 
casein makes up about 40 to 45 per cent, of the total nitrogen 
in human milk, the albumin plus globulin from 35 to 40 per cent., 
and the various non-protein nitrogenous constituents the re- 
maining 20 per cent. The amounts of the non-protein ni- 
trogenous constituents is not inconsiderable, and according to 
Denis, Talbot, and Minot^ approximate closely the amounts 
contained in blood. 

Non-protein Nitrogenous Constituents of Human Milk (Dennis, 
Talbot, and Minot) 

Total non-protein N 20 -37 mgm. per 100 c.c. milk 

Urea N 8. 3-16. mgm. per 100 c.c. milk 

Amino N 3.0- 8.9 mgm. per 100 c.c. milk 

Preformed creatinin N 1.0-1.6 mgm. per 100 c.c. milk 

Creatin N 1.9-3.9 mgm. per 100 c.c. milk 

Uric acid N 1.7-4.4 mgm. per 100 c.c. milk 

Caloric Value. — ^The caloric value of human milk is from 
700 to 800 calories per liter. 

^ Jour. Biol. Chem., vol. xxxix, 1919. 



HUMAN MILK 97 

Salts. — The following mineral elements are found in human 
milk: 

Phosphorus 0. 029-0. 041 gm. P2O6 per 100 gm. milk 

Calcium 0. 042 CaO per 100 gm. milk 

Magnesium 0. 0068 MgO per 100 gm. milk 

Sodium 0.016 NaaO per 100 gm. milk 

Potassium 0. 069 K2O per 100 gm. milk 

Iron 0. 0001-0. 0004 Fe203 per 100 gm. milk 

Sulphur 0. 014 per 100 gm. milk 

The phosphorus is present partly in inorganic, partly in 
organic form. The inorganic phosphorus is combined with 
calcium as calcium phosphate, the organic is mostly contained 
in the casein (about 40 per cent.). 

The calcium content may show great variations, according 
to Bahrdt and Edelstein^ from 0.03 to 0.08 per cent. There 
is a considerable diminution of calcium toward the end of the 
first year of lactation, which perhaps partly explains why some 
babies who have been fed exclusively on the breast too long 
become rachitic. Bahrdt and Edelstein found that in anemia 
of the mother and child the calcium of the milk was not dimin- 
ished. They could not increase the calcium content of the 
milk by feeding a diet rich in calcium. The older figures for 
iron (4 to 5 mgm. per liter) were probably too high, and with 
improved methods of analysis it has been shown that the iron 
content of human milk is very meager, probably rarely over 
1.6 mgm. per 100 c.c. of milk (0.0016 per cent.). Bahrdt and 
Edelstein were able to increase the iron in the milk of an anemic 
woman by giving iron as a therapeutic measure. Coincidently 
with this the hemoglobin percentage of her baby^s blood, who 
was also anemic, was increased. 

Citric Acid and Chlorids. — The citric acid content of human 
milk is 0.05 per cent., the chlorid content, 0.035 (CI). 

Biologic Substances. — Besides the constituents already men- 
tioned human milk contains biologic substances which may 
be divided into two groups (Engel): 

1 Jahrb. f. Kinderh., Ixxii, 1910. 
7 



gS PRACTICAL INFANT FEEDING 

1. The immune bodies, antitoxins, etc. 

2. The ferments. 

It is known that immunity can be conferred by the milk 
of the mother to the nursing infant, also that agglutinins may 
occur, and that the milk of a woman with typhoid fever may 
give the Widal reaction as well as the blood. It has been shown 
by Salge^ that diphtheria antitoxin may pass into the milk of 
a woman who has received it. A number of different ferments, 
such as lipase, amylase, etc., are present in milk, and even to 
a greater extent in colostrum. They are of considerable theo- 
retic interest, but of little practical significance as far as human 
milk is concerned. 

Variation in Milk Elements Through Changes in Food. — 
It is possible to change the chemical nature of the fat in human 
milk by changes in the kinds of fat fed in the food, and it has 
been shown that when certain kinds of fat are fed they pass 
unchanged into the milk. The chemical characteristics of the 
other food elements cannot be changed by diet. To a certain 
extent it is possible to change the amounts of fat or of protein 
by increasing or diminishing the amount of the food intake 
or by exercise. The sugar varies but little. (See next chapter.) 

Drugs in Milk. — ^According to Engel, the only drugs that 
have been shown with certainty to pass from the mother into 
the milk are potassium iodid, soda salicylate, aspirin, anti- 
pyrin, mercury, calomel, arsenic, and bromid. All of these, 
however, are present probably in only very small quantities, 
and it is doubtful if breast milk ever contains enough of any 
one of these drugs to do the baby any harm. 

Bacteriology. — Staphylococcus albus and aureus may be 
found in the milk of healthy women and are of no pathologic 
significance. The probable explanation of their presence is 
that they have penetrated from the outside a short distance 
into the milk-ducts, and are washed out again in the stream 
of milk. In such conditions as mastitis, where there is infection 
of the breast itself, streptococci may appear in the milk, but 
1 Jahrb. f. Kinderh., Bd. 68, 1904. 



HUMAN MILK 99 

most authors are agreed that ordinarily bacteria do not pass 
from the blood-stream to the milk. Lav/rence/ however, found 
typhoid bacilli in the milk of a nursing mother who had t3^hoid 
fever. In a few cases it has been proved that tubercle bacilli 
may occur in the milk of tuberculous women even if the breast 
is not diseased, but this is the exception rather than the rule. 
In the vast majority of cases tubercle bacilli cannot be demon- 
strated in the milk of a tubercular woman. 

1 Boston Med. and Surg. Jour., clxi, 1909. 



CHAPTER IV 
BREAST FEEDING 

Importance. — The importance of breast feeding cannot be 
overestimated. Despite the great improvements that have 
been made in artificial feeding in recent years, it is not easy 
to produce a baby by artificial feeding that can equal in any 
way a baby the product of successful breast feeding. 

The following bare statistical facts collected by Davis^ 
illustrate better than pages of argument or more numerous 
quotations the value of breast milk to the baby. 

1. In Boston in 1911 there were 621 deaths from diarrheal 
diseases in babies under one year of age. Of these, 534 were 
bottle fed. 

2. Of infants reaching the age of two weeks in Boston, 1 
in 5 dies before it is one year old if bottle fed, while if breast 
fed, only 1 in 30 dies. 

3. If all babies could be breast fed the deaths would be 
60 per cent. less. 

4. The actual number of infant deaths in Boston in 1911 
was 2248. Breast feeding would have saved nearly a thousand 
of these, and the death-rate instead of being 127 per 1000 births 
would have been 71. 

These figures are taken from but one city it is true, but 
similar figures hold for all cities of all nations. Many mothers, 
and, unfortunately, many doctors likewise, do not realize the 
importance of breast feeding, and the general tendency is to 
deprive the baby of the advantages of this on entirely insufficient 
grounds. It is, of course, true that some women cannot nurse 
their babies at all, but the number of these is not large, and 
the vast majority of all women can give their babies a start 
on the breast at any rate. It is in the first few weeks of life 

1 Amer. Jour. Dis. Chil., vol. 6, 1913, 1234. 



BREAST FEEDING lOI 

that artificial feeding is most difficult and more likely to be un- 
successful than at any other time. 

There are very few women at the present time who are 
unwilling to nurse their babies when they can. Rarely will 
such a woman be met with, even among the much maligned 
upper classes. If, after careful explanation of the advantages 
of breast feeding, the mother declines, without good reason, 
to nurse the baby, it is best to withdraw from the case entirely. 
In Manning's^ series of 1000 cases from private practice there 
was only one mother who refused to nurse. 

The following figures from this series show very well the 
average duration of nursing, and represent fairly closely, I 
believe, the situation among the better classes in the average 
community: 

Duration 
of nursing. Per cent. 

13 months 1.7 

14 months 1.0 

15 months 0.8 

16 months 0.4 

17 months 0.2 

18 months 0.9 

19 months 0.1 

20 months 0. 1 

21 months 0.1 

22 months 0.1 

22 months 0.1 

30 months 0.1 

36 months 0.1 



These figures make an interesting comparison with those of 
Mitchell,^ whose statistics are drawn from the hospital class, 
and represent 2819 cases: 

One Three Six Nine One Eighteen Two 

Nursed week months months months year months years 

not at all. or more, or more, or more, or more, or more. or more, or more. 



Duration 
of nursing. 

1 week 


Per cent. 
8.1 


2 weeks 


1.8 


3 weeks 


4 


1 month 


4.9 


3 months 


7.9 


4 months 


9.2 


5 months 


6.8 


6 months 


5.5 


7 months 


4.7 


8 months 


4.2 


9 months. . . 


7 5 


10 months 


4.5 


11 months 


3.0 


12 months. . . . . . 


6.1 



Mitchell.. 


.20.0% 80.0% 55% 


42% 


34% 27.0% 


9.0% 


2.0% 


Manning. . 


. 8.1% 91.9% 64% 


:4i% 


26% 11.8% 


1.6% 


0.3% 



1 Arch. Ped., vol. xxxvii, No. 4, 1920. 
* Amer. Jour. Obstet., 1912, Ixvi. 



I02 PRACTICAL INFANT FEEDING 

Sedgwick^ sent questionnaires in 1912 to a large number 
of doctors requesting information as to the ability of their 
wives to nurse. The results showed that about 80 per cent, of 
the wives of American physicians succeeded in nursing one or 
more children three months or longer. 

The Nursing Mother. — Nursing a baby is a natural, physio- 
logic process, and should not necessitate any great change or 
modification in a woman's habits provided she is leading a 
reasonable life already. A woman of even, quiet temperament 
usually makes the best nurser, and the unstable, nervous type 
of woman is likely to be unsuccessful. Women between the 
ages of twenty and thirty-five usually are able to feed their 
babies most successfully, but I have seen satisfactory nursing 
in women over forty. There seems to be no especial criterion 
by which to judge whether a woman will have an abundant 
supply of milk or not; other things being equal, a robust, strong 
woman is more likely to have good milk and plenty of it than 
a small, delicate woman; but many women in the pink of con- 
dition who lead the most healthy, athletic sort of Hves have 
practically no milk, and others, who seem frail and ill fitted 
for motherhood, will have an abundant supply. The best 
nursing mother that I have ever seen in private practice weighed 
under 100 pounds, and nursed her baby without supplementary 
feeding, and without apparent detriment to herself, up to ten 
months, at which time the baby weighed 20 pounds. 

A considerable amount of physical exercise, though not to 
the point of fatigue, is always advisable; and many nursing 
mothers during the first few months, especially if they take 
care of the baby themselves, do not get outdoors enough, and 
are likely to get into rather an unhealthy condition. Many 
women while in bed during the first few weeks have little milk, 
and this is often greatly increased after they get up and around. 
As an old Boston obstetrician used to say, a woman should be 
trained for the ordeal of labor just as an athlete is trained for 
a race. The same holds true of the nursing period, and the 
1 Jour. Amer. Med. Assoc, 1916, Ixvi, p. 1690. 



BREAST FEEDING IO3 

daily life and routine of a nursing woman should be as sane 
and as wholesome as possible. No woman, unless it is abso- 
lutely necessary for financial reasons, should attempt to do 
the housework and look after the baby into the bargain, whether 
the baby is breast or artificially fed. There is nothing that is 
more tiring than looking after a little baby day in and day out, 
and motherhood plus too heavy household cares is the cause 
of most of the wornout, young-old women that we all see so 
frequently. It is far better for a family to economize in some 
other way, and have a cook or a nurse girl. In these days this 
is often a real problem. 

The nursing mother should eat a reasonable, well-balanced 
diet, the same as any normal woman would eat. She must 
naturally eat a little more of it when she is nursing a baby, 
as she is feeding two individuals instead of one. Particularly 
is it advisable for her to have a considerable amount of protein 
in her diet, but only a sufficient amount to cover her own pro- 
tein needs, and that extra amount demanded by the milk. 
Hoobler^ has shown that animal protein is more efficient than 
vegetable protein in supplying nitrogen for milk and for the 
maintenance of nitrogen balance. Cereals and other starchy 
foods, fruits, and vegetables are valuable foods in any well- 
balanced diet, but the diet should not be one-sided in this respect, 
as these articles do not furnish enough protein. The practice 
that some nursing women have of stuffing with all sorts of rich 
food in the belief that they will produce more milk in so doing 
rarely does any good. 

There is no need of abstaining from green vegetables and 
acid fruits in the vast majority of cases, although many women 
have the idea that these are injurious to the baby. The best 
plan to follow is to let the mother eat anything she desires 
within reason, and then if any particular article is found to upset 
the baby, to omit this from the diet. 

A considerable fluid intake is necessary for every nursing 
mother, although here, again, no extremes are necessary. Three 
1 Amer. Jour. Dis. Chil., vol. 14, 1917, No. 2. 



I04 PRACTICAL INEANT FEEDING 

pints of fluid daily is probably a sufi&cient quantity for most 
women. In most eases it is not possible to produce more milk 
by drinking more fluid. There are a few women, however, 
who seem to need large amounts of fluid in order to have a 
sufficient quantity of milk, and in a munber of cases I have 
seen the milk supply become insufficient if they did not keep 
up this practice. The kind of fluid makes very little difference; 
plain water is just as good as cocoa, malted milk, or gruels, 
although the psychologic effect is probably rather important; 
a woman feels that she is accomplishing considerably more 
for her baby if she drinks 3 glasses of milk or of malted milk 
than would be the case with an equal amount of water. 

Care of the Nipples. — It goes without saying that the nipples 
should be kept scrupulously clean. SmaU amounts of milk 
are likely to remain after the nursing or to run out between 
the nursings. This decomposes, and an uncared for nipple 
may be a very dirty article indeed. Dirty nipples are the most 
frequent cause of breast abscess. It is the common practice 
to wash the nipples with a saturated solution of boric acid 
before and after nursing. The boric acid certainly does no 
harm, but it is doubtful whether it does any good, as an anti- 
septic strong enough to kill the bacteria present would erode 
the nipple. Plain boiled water is probably as efficient a nipple 
wash as anything else, although I suppose if a physician ordered 
it instead of boric acid solution, and a breast abscess developed, 
he would probably be considered very careless. It is important 
to wipe the nipple dry after it has been washed, as it is likely 
to keep in a much more healthy condition when dry than if 
it is allowed to stay wet. Little pads of gauze should be kept 
in place over the nipples between nursings, and a firm breast 
binder is acceptable to many women, especially during the 
first few weeks. If the nipples are rough, they should be smeared 
with lanolin after each nursing. 

Feeding in the First Few Days. — If the labor has been an 
ordinary one the baby can be put to the breast about twelve 
hours after delivery. The baby should be given as much water 



BREAST FEEDING IO5 

as he will take before this, however. The common practice 
is to give sugar and water, or, as many of the books say, water 
sweetened with saccharin. Neither one of these practices has 
an5^thing to recommend it; plain boiled water is just as good. 
Furthermore, a newborn baby does not need to have any food 
in the first few hours, and nature never intended that he should. 
By introducing sugar into the intestine at such an early time 
there is a possibility of interfering with the development of the 
natural bacterial flora, which was meant to develop upon colos- 
trum and not upon sugar. 

I believe it best to use three-hour intervals from the start, 
as the more the breast is stimulated, the more quickly is the 
milk likely to come in. If six- or four-hour intervals are used, 
the breast is naturally stimulated much less than with the 
three-hour intervals. Also, there is often some little difficulty 
in teaching a newborn baby how to suck, and the more often 
he practices, the quicker will he learn. The nursings should 
at first not be longer than five minutes, however, as the nipples 
are at first very tender. In the first three days the baby gets 
very little nourishment, and loses weight, partly as a conse- 
quence of this and partly from other causes (see Chapter I). 
The breast milk should be in normally by the third or fourth 
day, and if it is delayed longer than this it is best to start a 
weak artificial feeding given in small amounts after each breast 
feeding. The milk is often considerably delayed in coming 
into the breast, and breast feeding should never be discontinued 
on account of this. If the baby is rather small and weak, and 
does not nurse well, stimulation of the breasts as advocated by 
Sedgwick often seems to help a good deal in producing secre- 
tion, and it is certain that failure of breast feeding is often 
caused by insufficient stimulation of the breasts during the 
early days. 

Directions for Milking (Sedgwick^). — "The breast is grasped 
about 1 or 2 cm. back of the colored areola, and a milking motion 
is carried out toward the nipples. No massage of the breast 
1 Jour. Amer. Med. Assoc, 64, p. 417, 1917. 



Io6 PRACTICAL INFANT FEEDING 

proper is allowed, as it is of little if any value, and sometimes 
causes traumatic inflammatory reaction. If we consider the 
anatomy of the breast, we learn that the ducts which contain 
the milk extend but a short distance back of the areola. Any 
one who has ever seen a cow knows that the teats are milked 
and not the cow's bag, and yet we often find head nurses, physi- 
cians, and even pediatricians giving instructions to milk or 
'massage' the breast itself. If our method is intelligently followed 
it is possible to keep the mother of a premature infant from 
losing her milk. I have seen some such mothers supply not 
only milk for their own baby but also enough for another infant." 

The baby should usually stop losing weight at about the 
fourth day, and if he does not start to gain by this time it is 
best to keep on with the complemental feeding, as in this way 
much valuable time can be saved, and an excessive loss of weight 
can be prevented. This is rather important, as a too large 
loss of weight in the early days may be a severe handicap to a 
small baby. The chart (Fig. 2), taken from my case records, 
shows about what the weight of a normal newborn breast-fed 
baby can be expected to do in the first two weeks. 

By the time the baby is two or three weeks old he should 
have regained his birth weight and should be gaining regularly. 

A newborn baby usually passes meconium soon after birth, 
and continues to pass it until the milk comes in, after which 
the stools begin to take on the characteristic golden yellow color. 
If no meconium has been passed in the first twenty-four hours 
it is well to give | teaspoonful of castor oil, as it is not uncommon 
for decomposing retained meconium to cause fever, and more 
rarely convulsions. In general, however, it is best to avoid the 
indiscriminate use of castor oil in newborns, and to give instruc- 
tions to the nurse that it shall not be given, as many of them 
have a bad habit of giving castor oil every day, for just what 
reason I have never been able to find out. 

Gain in Weight. — The best index of the well being of a baby, 
whether breast or bottle fed, is a steady and satisfactory gain 
in weight. A breast-fed baby should gain from 6 to 8 ounces 



BREAST FEEDING 



107 





















■^ 


' 


r 






r 
















1 


z 


3 


4 5 


6 


7 


8 


9 


i.0 


11 


■ 
12 


13 


14 


15 


16 


17 










6 rtt8» 7 oz. 












































H n 6 •* 


































# 










» 9 5 '• 






























» 


A 












oh 4 «♦ 




























«( 
















« " 3 " 




























1 
















H M 2 " 


























/ 


















« « 1 " 


d 
























/ 


















5 « 15 " 


^ 


^ 






































• - 14 " 








































•» •• 13 •» 




\ 








































" " 12 " 












































•» - 11 •» 




\ 






































" " 10 ♦» 




h 






•' 


# 































« » 9 n 






\ 






r 


\ 






> 


r 






















ft » g n 






\ 




/ 


) 




^ 


4^ 
























» - 7 « 






^ 


i- 


/ 


































• - 6 »♦ 








W 


i 


























































__j 








— 













Fig. 2. — Baby W. Birth weight, 6 lbs. 1 oz. Loss, 11 oz. Lowest weight 
on fourth day. Birth weight regained on the thirteenth day. 



BABY'S WEIGHT RECORD 



WEIGHT OF BABY 


LBS... 
















■ 


DATe 


t«« 


LBS. OZS 


OATl 


wVeks 


LBS. OZS, 




DATE 


ASE I^ 


LBS. Oz| 


DATS 


AOt IN 
WCCKS 


LBS. PZi 






1 










14 












27 










40 










2 










15 












28 










41 










3 










16 












29 










42 










4 










17 












30 










43 










5 










18 












31 










44 










6 










19 












32 










45 










7 










20 












33 










46 










8 










21 












34 










47 










9 










22 












35 










48 










10 










23 












36 










49 










1 1 










24 












37 










50 




■■"* 






12 










25 












38 










51 










13 










26 












39 


z 








52 







Fig. 3. 



Io8 PRACTICAL INFANT FEEDING 

a week during the first six months, and 4 to 5 ounces a week 
the next three months. Anything less than this is not satis- 
factory. Accurate weekly weighing is of the utmost importance, 
and it is often surprising to see how many otherwise intelligent 
doctors and mothers neglect this. It is very convenient to have 
little printed cards,^ such as is shown in Fig. 3, to give to 
every new mother, so that she can have an accurate record 
which the doctor can scan at a glance to see how the baby is 
doing. 

Plotting the baby's weight against a theoretic curve is 
a pernicious practice, as babies vary so much in their initial 
weights that often the mother is imnecessarily worried by the 
failure of the baby to follow the curve. Another pernicious 
practice after the first three weeks is to weigh the baby every 
day or so. No baby gains regularly every day, and may often 
lose several ounces, which he will gain back the next day. Daily 
weighing is one of the most potent sources of worry to a nervous 
mother. 

Intervals of Nursing. — There is always much discussion 
concerning the correct nursing interval. With breast-fed 
babies the three-hour interval has seemed to me the most satis- 
factory in the vast majority of cases. Only in the case of very 
weak or premature babies, who take little at a feeding and 
do not nurse vigorously, is a more frequent nursing necessary. 
Many breast babies do very well on four-hour feedings, par- 
ticularly if the baby is robust and the supply of milk abundant. 
Absolute regularity should be adhered to in the nursing hours; 
one cannot start to train a baby too soon, and it is the babies 
trained in regular habits of eating and sleeping who, as a rule, 
do best. Undoubtedly many breast-fed babies do well who 
are fed every time they cry, but these are the exception rather 
than the rule. One of the hardest things to teach dispensary 
patients is that regular nursing hours are better than irregular. 
A good start means a great deal to the baby, and to the peace 
of mind of his mother, and a really good obstetric nurse will 
1 These are kindly supplied me by E. F. Mahady Co., Boston. 



BREAST FEEDING 109 

do wonders in getting the daily routine running smoothly. 
Some writers believe that a baby should never be waked from 
sleep to nurse. The best answer to this is that as a great many 
small babies sleep most of the time, they would get very little 
to eat if this rule were adhered to. In my opinion a baby should 
always be waked to nurse. He will usually go to sleep again 
immediately afterward. 

Amoimt at Each Feeding. — ^A baby rarely gets the same 
amount at each feeding during the course of the day, but the 
twenty-four-hour amount is likely to remain fairly constant. 
The supply of breast milk is usually most abimdant in the 
morning and scantiest at the late afternoon and evening feed- 
ings. Most of the milk is obtained in the first five minutes of 
nursing, although the richest part of the contents of the breast, 
the "strippings," containing a high fat percentage, is not with- 
drawn until toward the end of the nursing. Most babies nurse 
about fifteen minutes as a rule. A few unusually strong, greedy 
babies will empty the breast in much less time than this, how- 
ever, and a weak baby may remain at the breast for half an 
hour or more. In general, if the baby nurses over twenty 
minutes it indicates that the breast milk is scanty in amount, 
and that by keeping on nursing the baby is hoping against hope 
to squeeze out a few drops more. 

Substitution of One Bottle Feeding. — It does no harm, 
and is indeed a good idea in many cases after the first month 
to substitute one bottle feeding for a breast feeding. This gives 
the mother a chance to get out and see her friends, and to get 
away from the baby for a while, which may be just what she 
needs. The usual feeding substituted is the 3 p. M. feeding. 
This leaves the mother free from 12 m. to 6 p. m. 

Night Feedings. — There is no reason why a normal baby 
over a month old should be fed in the middle of the night, and 
it is always a good plan to have the baby broken of the 2 a. m. 
feeding as soon as possible. I have known this to be done in 
a good many cases before the mother and baby left the hospital, 
and I always try to have it accomplished by the obstetric nurse 



no PRACTICAL INFANT FEEDING 

before she leaves, so that the mother will not be bothered with 
it. The best plan to follow is to use a somewhat longer interval 
after the 6 p. m. feeding, making the last feeding at 10 or 10.30, 
being sure that the baby gets plenty, with the addition of a 
small complemental feeding if necessary. This may carry him 
through the night; if it does not, it is best to give a little water 
for a few nights, or to let him "cry it out." In these days the 
old idea of waking up every few minutes during the night to 
feed the baby is, or should be, obsolete. 

Stools. — The stools of a breast-fed baby are usually two or 
four daily, golden yellow in color, mushy in consistency, and 
have an aromatic, sour smell. Variations may occur quite 
normally, however. A not inconsiderable number of perfectly 
normal breast-fed babies will have as many as six or seven 
green, curded stools daily, without any harm whatsoever. 
Other normal babies will have a stool only every other day. 
Mothers have it clearly fixed in their minds that a baby must 
move its bowels every day in order to be well. This is not so, 
and many well babies very frequently skip a day. If loose 
green stools or constipated stools are accompanied by symp- 
toms of gas, vomiting, excoriated buttocks, etc., the condition 
is, of course, abnormal, and calls for treatment, but it is sur- 
prising to see how many breast-fed babies will have all during 
the nursing period five or six green, loose, curded stools a day 
and still gain regularly and do well. 

Weaning. — In most cases a baby should not be allowed 
to nurse at the breast after the ninth month, and it is well to 
have him accustomed to the bottle before this time so that 
there will be no trouble with the weaning. The best way to 
wean is to gradually replace the breast feedings by the bottle, 
substituting a bottle feeding for a breast feeding every two or 
three days, until the baby is getting the breast only twice a day. 
When this stage has been reached he may be weaned entirely. 
In most cases there will be little difficulty with weaning, espe- 
cially if he has been previously accustomed to the bottle or the 
spoon. In a few cases considerable difficulty is experienced, 



BREAST FEEDING III 

owing to the fact that the baby will not take the bottle if he 
has any chance of getting the breast. If this difficulty arises 
the weaning must be abrupt and the breast milk dried up at 
once. After the baby has gone for a few feedings without any- 
thing to eat, and once he clearly understands that there is to 
be no more breast milk for him, it is usually plain sailing. It 
is best to have the mother out of sight when the bottle is given, 
until the baby becomes well accustomed to it. As soon as he 
is taking bottle milk well, cereal and soup or zwieback may be 
started, according to the principles of artificial feeding laid 
down in another chapter. 

In hot climates during the summer, where the purity of the 
milk supply is uncertain, it is usually best not to wean during 
the hot weather. In places where the milk supply is good, and 
the weather is not excessively hot, weaning can be done at any 
time of the year. 

The mother usually experiences little difficulty in drying 
up her breasts. Enough Epsom salts should be given each day 
to produce two or three watery movements, and she should 
take as little fluid as possible. 

Diffictilties Arising During Lactation. — Depressed or In- 
verted Nipples. — Not a few women have poor nipples. They 
may be either merely rather flat, and therefore difficult for the 
baby to take, or they may be actually inverted, and therefore 
prevent nursing entirely. The time to treat flat nipples is 
several months before the birth of the baby. The mother 
should be instructed to pull them out several times daily, and 
if she does this faithfully, they may become considerably elon- 
gated. With actually inverted nipples little can be done, and 
the use of a nipple shield is necessary. Some babies take 
nipple shields very weU; others refuse them absolutely. In 
general, it has seemed to me that nipple shields are most 
unsatisfactory. 

Cracked Nipples. — If care is taken, cracked nipples should 
not develop. The baby should take not only the nipple in his 
mouth but also a considerable area of the areola behind the 



112 PRACTICAL INFANT FEEDING 

nipple. If this is done the nipple suffers less trauma. It is 
especially important to keep the nipples dry and to leave no 
decomposing milk on them. If they show a tendency to dryness 
and hardness, they can be smeared with a little lanolin after 
each nursing. 

If fissures develop, the nursing may be extremely painful 
to the mother, often so much so that it becomes practically 
impossible. If cracked nipples could be left alone for a few 
days they would heal readily, but it is the continual irritation 
and pulling of the baby upon them that keeps the cracks open 
and prevents healing. The best plan to follow is, first of all, 
to try a nipple shield, and if this does not work, to remove 
the baby from the breast in question for several days, and feed 
him artificially, taking care, however, to empty the breast 
with a pump at regular intervals, in order to keep up the milk 
secretion. During the few days that the baby is not taking the 
breast applications of a 5 per cent, silver nitrate solution to 
the fissures has seemed to me to be the most ejQBicient method 
of treatment. There is little use in trying to heal cracked nipples 
with the baby sucking at them every three or four hours; if 
he is fed otherwise, and the crack given a chance to heal, the 
condition usually clears up readily. 

Caking of the Breast. — If there is a large amount of milk 
in the breast, particularly during the first few weeks of lacta- 
tion, and the baby on account of feebleness or otherwise, does 
not empty it completely, caking is likely to occur. This is shown 
l)y the presence of hard, sometimes slightly tender lumps in 
the breast, particularly in the dependent portions. This should 
not be confused with mastitis. The treatment is to see that the 
breast is completely emptied after each nursing, with a breast- 
pump if necessary. 

Mastitis and Abscess, — ^Mastitis means an actual inflamma- 
tory condition of the glandular tissue of the breast. The infec- 
tion practically always gets in through the nipple, and is usually 
due to the staphylococcus. Cracked nipples and undue caking 
of the breast may be important causes. Any septic condition 



BREAST FEEDING II3 

of the baby may be also a cause. According to Norris, mastitis 
occurs in from 0.5 to 4 per cent, of all nursing mothers, par- 
ticularly in the early weeks of lactation. It is very likely to 
start with a chill, and an abrupt rise of temperature to 101° 
or 102° F. The infected part of the breast is hot, red, and 
tender. The baby should at once be prohibited from nursing 
on the infected breast, although he may continue to nurse on 
the normal one in most cases, unless the mother is too sick. 
The object of treatment in mastitis is to prevent the condition 
from going over into actual abscess formation, and for this 
purpose the continued application of cold in the form of an ice- 
bag is the most efficient means. If a high temperature lasts 
for more than forty-eight hours it is probable that pus is present, 
and that surgical intervention will have to be resorted to. If 
in conjunction with the continued high temperature the mass 
in the breast increases in size, redness, and tenderness, and 
becomes fluctuant, it is certain that a breast abscess is present, 
the treatment of which is incision and drainage. After most 
cases of single mastitis the supply of milk on that side will be 
considerably diminished, but with a complementary feeding 
nursing at that breast may be continued. After abscess there 
will probably be no milk in the breast, and half-substitute 
feeding will have to be employed. 

Acute Disease in the Mother. — ^When a nursing mother 
develops an acute infectious disease it is often a question of 
nice judgment whether the baby should continue nursing or 
not. Although it is undoubtedly possible in some cases for the 
baby to continue nursing during certain long-drawn-out febrile 
conditions in the mother, and although in the last few years 
a number of pediatricians have advocated the continuance of 
nursing during such diseases as tj^hoid fever and pneumonia, 
my personal feeling is that it is best to wean the baby if the 
mother is going to be sick more than a few days. Artificial 
feeding is so successful now compared to what it used to be 
that there is a good deal more danger of the baby's going wrong 
if nursing is continued than if he is weaned. Furthermore, 



114 PRACTICAL INFANT FEEDING 

a really sick woman, with any febrile disease which is going to 
last for more than a few days, has need of all her energy, and 
has none to spare in feeding a baby. In such conditions as 
tonsillitis or uncomplicated influenza there is no need of weaning. 
In the longer infections, as I have said, it is generally best to 
discontinue nursing, although, of course, no hard-and-fast rules 
can be laid down, and each individual case has to be decided 
according to circumstances. 

Pregnancy. — If a nursing mother becomes pregnant again 
the baby should in most cases be weaned. Here again, how- 
ever, one must not be too dogmatic, for special circumstances 
may have to be considered. If the baby is a small one and 
needs breast milk, if it is during the very hot weather, if the 
baby is acutely sick or is recovering from some infectious disease, 
it is better to let nursing continue for a month or two. It is 
undoubtedly possible for some women to carry one baby in 
utero and nurse another; but, unless there are some special 
reasons to the contrary, the nursing baby should be weaned 
as soon as pregnancy has been recognized. In the South during 
the summer the question of weaning a baby on account of 
acute infection or pregnancy in the mother has to be regarded 
in a somewhat different light from what it is in the North. 
So many artificially fed babies die every summer in the South 
from the diarrheal diseases that breast feeding must never be 
discontinued at this season if it is humanly possible to con- 
tinue it. 

Menstruation. — Some women menstruate while nursing, 
some do not. It is a clinical fact that many babies are upset 
during the first day or two of menstruation. This is shown by 
fussiness, colic, green, loose stools, and sometimes vomiting. 
The cause of this is not clear. It is not unreasonable to sup- 
pose that there should be changes in the breast milk during 
menstruation, as the breasts and the uterus are intimately con- 
nected organs. There is much difference of opinion as to this, 
however. Czerny and Keller say that there is no chemical change 
in the breast milk during menstruation. Langstein and Meyer 



BREAST FEEDING II5 

believe that while there is no change in composition, there is 
a diminution of milk, which makes the baby fretful. This 
question has been investigated by Rantenga and Filippo.^ 
They examined the breast milk of menstruating women, some 
of whose babies were upset by the menstruation, some not. 
They studied particularly the lactose and chlorid content, and 
found that the lactose and chlorids were normal in all cases 
where the baby was doing well (7.3-7.8 per cent, lactose — 24-43 
mgm. chlorids per 100 c.c. of milk). In another series of cases 
where the babies were restless and irritable, and were having^ 
loose green stools, they found a low lactose and a high chlorid 
content. The lactose ran as low as 4 per cent, and the chlorids 
as high as 168 mgm. per 100 c.c. of milk. This condition of 
the milk they found most likely to be present twenty-four hours 
before the onset of the menses. They also found that in all 
cases where the baby was upset the quantity of milk was de- 
cidedly less than normal. This is the first real light that has 
been shed on the subject. It is practically never necessary to 
wean a baby on account of menstruation of the mother. The 
upset lasts only a day or two in most cases, and if it should last 
longer than this, bottle feedings can be given and the breasts 
pumped until menstruation ceases. 

Contraindications to Nursing. — Any chronic, wasting disease 
in the mother is a contraindication to nursing. Under this 
head come cancer, tuberculosis, chronic nephritis, secondary 
anemia or any other blood disease, hyperthyroidism and decom- 
pensated heart disease, and diseases of the nervous system. 
There is no particular reason why an epileptic should not nurse 
her baby if the attacks are infrequent and if the nursing seems 
to do her no harm. No woman with tuberculosis in any form 
ought to nurse her baby, as small babies are extremely suscep- 
tible to tuberculosis, and the baby will certainly get it if he 
is in close association with the mother. Syphilis, unless it takes 
such a form that the mother is feeble, on the other hand, is art 
indication for breast feeding rather than a contraindication,, 
1 Ztschr. f. Kinderh., vol. 14, No. 182, 1916. 



Il6 PRACTICAL INFANT FEEDING 

as if the mother is syphilitic, the baby probably is, and needs 
the very best food possible. Most women with neurasthenia 
are too nervous to nurse their babies. Women who have had 
eclampsia and who have been delivered prematurely on this 
account should not nurse their babies, as their milk is usually 
poor, and they are not in good condition. In cases where the 
mother has had a little albumin in the urine, and a somewhat 
increased blood-pressure during the latter months of pregnancy, 
nursing does not necessarily need to be prohibited, but the 
baby needs to be watched carefully, as it is very likely that the 
breast milk will not be abundant in amount or of particularly 
good quality. 

The Abnonnal Breast-fed Baby. — Vomiting in the Early 
Days. — Not a few newborn babies vomit or regurgitate con- 
siderably during the first week, and often are unnecessarily 
weaned on this account. This is a great mistake, as this type 
of vomiting almost always ceases as soon as the mother is out 
of bed and lactation has been well established. Many times I 
have seen babies who were vomiting nearly every feeding in 
the hospital stop as soon as the baby and mother went home, 
and the mother began to be up and around. Particularly if 
the colostrum corpuscles persist in the milk for a longer period 
than is usual, the baby is likely to vomit. Colostrum is normally 
yellow in color, and in some cases this yellow color is greatly 
intensified, and may persist for a week or ten days. In several 
cases with this deep yellow breast milk that I have seen the 
baby has vomited excessively. The yellow color is not always 
due to colostrum corpuscles, as in one case the milk was a deep 
lemon color, and no colostnun corpuscles could be seen under 
the microscope. In this type of milk the fat is usually, but not 
always, high. The pigment is probably a combination of carotin 
and xanthophyll (see Chap. Ill), and is contained in the fat 
globules. These pigments come from the chlorophyl in green 
vegetables and fruits, and in any case with yellow breast milk 
where the baby is upset these should be omitted temporarily 
from the diet. 



BREAST FEEDING II7 

The most common cause of vomiting in the early days is 
improper technic in taking care of the baby. This occurs espe- 
cially in hospitals, where one baby may have five or six different 
nurses take care of him during the course of the day, each with 
different methods of handling. He may be kept quiet after 
nursing or he may not be — one nurse may handle him with 
quick, jerky motions, another slowly and deliberately — ^his 
diapers may be changed when they are wet or dirty, or they 
may stay on him for hours. All these things upset a baby, 
and there is no question that in many of these vomiting babies 
the trouble is caused by "too many cooks." Newborn babies, 
as a rule, do far better at home than they do even in the best 
lying-in hospital, although in the days when so many people 
live in small apartment houses the lying-in hospital is a necessity. 
There should be special nurses for the nursery, however, whose 
sole duties should be to look after the babies. 

Another cause of vomiting in the early days of life is an 
overabundant supply of breast milk. A baby a week old natur- 
ally has a good deal smaller stomach than an older baby, and 
if the breast is a fast one and there is a large amount of milk 
in it, he may get so much at each feeding that he vomits the 
overflow and sometimes the rest besides. The treatment of 
this type of vomiting is simple and satisfactory, and consists 
in increasing the interval between nursings, reducing the time 
of each individual one, and in stopping for a minute or two 
several times during the nursing. 

Occasionally a baby will be seen who vomits more persistently 
without apparent reason, and all attempts at treatment are 
unavailing. No baby should be weaned during the first two 
weeks on account of vomiting, no matter how bad it is. If the 
vomiting is persistent and resists all measures of treatment, 
pyloric stenosis should be considered, and appropriate treat- 
ment instituted. In a few cases, although pyloric stenosis is 
evidently not present, and all methods of treatment are tried, 
the vomiting persists, and the baby does not gain weight. These 
babies must be weaned. 



Il8 PRACTICAL INFANT FEEDING 

Underfeeding. — The underfed breast-fed baby is common. 
Underfeeding is manifested especially by failure to gain properly 
— 1, 2, or 3 ounces a week instead of the usual 6 or 8. There are 
usually, but not always, symptoms of hunger, sleeplessness, irri- 
tability, etc. The stools may be small and constipated, or typical 
"starvation" stools may be passed, which are rather small in size, 
brown in color, contain considerable mucus, a few curds, and seem 
sticky in consistency. Such stools as this mean usually not 
indigestion, but underfeeding. The underfeeding may be 
qualitative or quantitative, that is, the breast milk may con- 
tain an insufficient amount of one of the individual food ele- 
ments, particularly the fat, or it may be deficient in both quantity 
and quality. The most common deficiency is a lack of fat, 
and the fat percentage may be as low as 0.50 per cent. Com- 
bined with the low fat percentage is usually a high protein per- 
centage, which may or may not give rise to symptoms of indiges- 
tion. 

For practical purposes cases of underfeeding may be divided 
into two groups: 

1. Those which are simply not getting enough to eat, but 
have no symptoms of indigestion. 

2. Those which do not get enough to eat, and have indiges- 
tion also, usually from a too high protein percentage in combi- 
nation with a low fat. The treatment of the first group is most 
satisfactory, and consists simply in giving the baby extra food 
in the shape of cow's milk modification. If there is not much 
deficiency in the breast milk the artificial feeding can be given 
immediately after each breast feeding in amounts suitable to 
the exigencies of the case and the age of the child. The amount 
to give can be determined approximately by weighing the baby 
before and after each breast feeding, and by finding out in this 
way how much he gets from the breast. 

A series of such observations conducted over a period of 
several days give considerable information, and enables one to 
regulate accurately the amount of extra bottle milk which 
should be given. The following tables show the amount of 



BREAST FEEDING 



119 



breast milk that an underfed baby of six weeks was getting, 
and also how the amount diminished in the course of two weeks: 



January 19th: 



3.30 A. M. 

7.00 « 
10.00 « 

1.00 p. M. 

4.00 « 

7.00 « 
10.00 « 

Total. . 



..2 

..4 

..2 

..3.5 

..1 

..5 

..1 



oz. 



. 18.5 oz. 



January 20th : 7.00 a. m. . . . 3.5 oz. 



10.00 
1.00 
4.00 
7.00 

10.00 



p. M. 



.2.5 

.3 

.1 

.1.5 

.3 



Total. . . 14.5 oz. 



January 21st: 



4.00 A. M 2 

7.00 « 2 

1.00 p. M 3 

4.00 « 3.5 

7.00 « 3 

10.00 « 3 



Total 16.5 oz. 



The next three-day period, taken about two weeks later, 
shows how the supply of breast milk had diminished: 



6th: 7.00 a. M 


3 oz. February 7th: 7.00 a. m.. . 


. . 3 oz. 


10.00 " ... 


1 « 


10.00 " .. 


.. 2 " 


1.00 p. M. . . . 


2 « 


1.00 p.m... 


.. 2 " 


4.00 « ... 


1 « 


4.00 " .. 


.. 1 " 


7.00 « ... 


3 « 


7.00 « .. 


.. 2 « 


10.00 « ... 


1 « 


10.00 « ,. 
Total. . . 


.. 1 " 


Total 


11 oz. 


. . 11 oz. 


February 


8th: 4.00 a.m... 


. loz. 






7.00 " . . 


. 3 « 






10.00 " . . 


. 1 « 






1.00 P.M... 


. 2 « 






4.00 " .. 


. 2 « 






7.00 « . . 


. 2 " 






10.00 " . . 
Total. . . 


. 2 « 






.13oz. 





The giving of bottle milk immediately before or after the 
breast feeding is known as complemental feeding, and is usually 



I20 PRACTICAL INFANT FEEDING 

the best way to give extra artificial feeding, as the breast is 
stimulated with each nursing act in this way, whereas if several 
bottle feedings were substituted for several breast feedings, 
the breast would get no stimulus at these times, and the already 
deficient store of milk might be further reduced. There is no 
contraindication to giving cow's milk and breast milk together; 
indeed, it seems as though cow's milk were easier to digest 
when in the stomach at the same time with breast milk, and 
it is rare to have any sjanptoms of indigestion during mixed 
feeding of this sort. If the mother's supply of milk is very scanty 
indeed, and she has only enough to feed the baby perhaps 
twice during the day, it is best to let her do this, and to substitute 
a bottle for the other breast feedings. This is known as supple- 
mental feeding. Unless the mother can give the baby two 
full breast feedings a day it is best to discontinue nursing alto- 
gether. 

A baby should never be weaned simply because he does not 
get quite enough to eat on the breast; every few ounces of breast 
milk that he can get will help him, and the deficiency can be very 
easily made up with the bottle. Mothers and doctors, as a rule, 
do not appreciate this, and have a most unfortunate tendency 
to discontinue nursing entirely if the baby does not gain weight 
satisfactorily or if he seems hungry. 

If the mother is leading a reasonable life, is well physically, 
has no worries, and is eating and drinking plenty it is not pos- 
sible to do much toward improving either the quantity or 
quality of her milk. If she is overtired or overnervous the 
removal of the causes that have produced these conditions may 
bring about a betterment of her milk; if she does not eat the 
right sort of food or drink enough, a better balanced diet will 
help her. 

The treatment of the babies who are underfed and who 
have symptoms of indigestion is more difiicult. Here the baby 
does not gain weight, is fussy and irritable, is likely to vomit 
considerably, to have a good deal of gas and colic, with loose, 
green, curded stools. The difficulty here is also likely to be 



BREAST FEEDING 121 

caused by a too low fat and a too high protein percentage. 
The fat may be down to 0.50 per cent, and the protein up to 
3 or 3.50 per cent. This type of milk is most likely to be seen 
in overworked, underfed women of the lower classes, or in highly 
strung nervous women of the upper classes. A good deal may 
be done for the milk of the underfed, overworked woman by 
mental and physical rest and a suitable diet, especially high 
in fats. Complemental feeding should, of course, be used at 
the same time. The highly strung, nervous woman, who has 
a poor milk more on account of the composition of her nervous 
system than on account of any errors in diet or hygiene, is a 
more difficult problem, and it may be necessary to wean the 
baby in such cases.. 

Overfeeding. — If a baby has indigestion with artificial feed- 
ing it is comparatively easy to tell from the symptoms and 
the character of the stools which food element is causing the 
trouble. This is not so easy with a baby fed on the breast. 
The stools of any breast baby with indigestion are likely to 
look very much the same, whether the trouble is due to fat, 
sugar, or protein. Occasionally, when the breast milk contains 
a very large amount of fat the stools may appear oily. Micro- 
scopic examination of the stools is by no means always reliable 
if the baby is breast fed, for there is so much fat in any good 
breast milk that there is likely to be a large amount of it in the 
stools of any normal breast-fed baby. The general symptoms 
of overfeeding or of indigestion due to any one of the food ele- 
ments are vomiting, colic, gas, frequent green curded stools, 
poor sleeping, and failure to gain properly. 

Much trouble is caused by too frequent and irregular feed- 
ings. The baby's stomach does not get a chance to empty 
itself before new food is introduced; part of this will probably 
be vomited, the rest enters the small intestine, where, on account 
of its large amount, it cannot be wholly absorbed. What is 
not absorbed undergoes fermentation, with the production of 
loose green stools, gas, and colic. 

The first thing to do is to increase the interval between the 



122 PRACTICAL INFANT FEEDING 

feedings if it is too short, and to see also that the baby is fed 
with absolute regularity. Also a couple of tablespoonfuls of 
lime-water, or of plain boiled water, can be given before each 
nursing, in order to dilute the milk, and the time of nursing can 
be shortened from fifteen or twenty minutes to eight or twelve 
minutes. Most babies who are getting simply too much milk 
of normal composition at too frequent intervals will respond 
readily to this treatment. 

If these changes do no good, the composition of the breast 
milk should be determined by analysis. The sugar varies the 
least of any of the food elements; the fat and the protein may 
vary considerably. The German school believes that all breast 
milk is good milk, that excessive amounts of the individual 
elements do no harm, and that disturbances of digestion or of 
nutrition are always due to underfeeding, overfeeding in toto, 
sickness of any sort in the baby, or faulty methods of caring 
for him. While it is imdoubtedly true that many breast-fed 
babies thrive on milks of markedly abnormal composition, 
it is also true, in our opinion, that abnormality in the composi- 
tion of the breast milk accounts for indigestion in a great many 
cases. Breast milk analyses are entirely unreliable unless the 
milk is obtained in a certain way, and unless the analysis is 
done by exact quantitative methods by a competent chemist. 
Either the whole contents of the breast should be sent for 
analysis or the middle portion of the nursing. In practice it 
is usually simpler to obtain the middle portion of the nursing. 
The baby is permitted to nurse about a quarter of his usual 
time, then an ounce or two of breast milk for analysis is expressed 
either manually or with a pump. The fore-milk or first por- 
tion of the nursing is very low in fat, the strippings, or last 
portion, is rich in fat. The middle milk gives a fairly accurate 
representation of the average composition. If the percentage 
of fat is found to be too high, the best way to reduce it is to 
have the mother eat less food in general, and exercise more. 
If the percentage of protein is too high, exercise and freedom 
from nervousness and household cares may diminish it. Dimin- 



BREAST FEEDING 1 23 

ishing the protein in the food probably has little effect in 
diminishing the protein in the milk. Although the sugar may 
not be excessive in amount, it may none the less be the cause 
of indigestion. There is no satisfactory way of influencing the 
amount of sugar. 

In general it is rather difficult to treat a breast-fed infant 
with indigestion. With bottle feeding we can change the amounts 
of the various food elements in the diet at will, and we can 
usually tell very easily by the stools which element is causing 
the trouble. With breast feeding, on the other hand, we are 
working at a considerable disadvantage. The picture is not 
nearly so clear, and it is much more difficult to change the 
character of the milk. Furthermore, indigestion may occur 
even when the breast milk is apparently perfectly normal in 
composition. In this group of cases particularly, but also in 
any case with an excessive number of stools, and evidences 
of intestinal fermentation, an ounce or two of fat-free lactic 
acid milk or buttermilk given immediately after the shortened 
nursing period may help a great deal, and is one of the most 
satisfactory methods of treatment. A half teaspoonful of pow- 
dered casein (Larosan, Casec) dissolved in a tablespoonful of 
water, and given after each feeding, is also efficient in cases 
which are due to sugar or fat fermentation. 

It is our duty to go through all methods of treatment before 
weaning the baby, and in most cases weaning is not necessary. 
Occasionally, however, the baby fails to do well, no matter 
what we do, and breast feeding has to be discontinued. 



CHAPTER V 

THE DEVELOPMENT OF MODERN ARTIFICIAL 
FEEDING! 

The artificial feeding of infants has been, is, and probably 
will continue to be a much discussed subject. Our opinions 
regarding it are constantly changing and developing; its litera- 
ture is assuming enormous proportions, and each year we are 
learning more and more concerning the fundamental nutritional 
processes of the infant, upon which all nutritional therapy 
depends. It is in a constant state of flux; certain ideas are in 
the foreground for a few years and then gradually recede, leav- 
ing, however, their faint or pronounced marks upon the fabric 
of the whole. The healthy infant has the power, in a large 
measure, of adapting itself to widely varying artificial diets; 
this accounts to a great extent for the success that pediatricians 
in different parts of the world have had, using their own par- 
ticular methods, which may differ considerably. There is no 
one way to feed an infant; it is true that he must be fed a food 
that furnishes enough fuel value; also that he must have a food 
which he can digest and which contains the proper materials 
for the growth of his body; but it is possible to meet these 
demands in a variety of ways. We know, even at the present 
time, comparatively little about the factors which are con- 
cerned in the disturbances of digestion and of nutrition; further- 
more, babies fed according to one method are likely to have 
somewhat different types of disturbance than those fed accord- 
ing to another method; therefore there is plenty of chance 
for different ways of looking at these disturbances, and for 
difference in their classification. 

* This chapter appeared in the Boston Medical and Surgical Journal, vol. 
dxxii, No. 13, 1920 and I am indebted to the editors for permission to re- 
print it. 

124 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 25 

Liberality, broadness of vision, and respect for the opinions of 
others are essential in medicine; in no branch of medicine are these 
qualities more essential than in infant feeding. There are many 
ways of approaching the subject, many viewpoints of value besides 
the ones which we may ourselves happen to hold, and it is vital in 
order to have a clear vision of the subject to give heed to the thoughts 
of eoery competent observer, to adopt what seems good in his teach- 
ings, and to amalgamate it with our own ideas. 

Therefore, it should be of value to consider the development 
of modem infant feeding, the opinions that have been held 
by the great teachers of the subject, their influence upon those 
who have followed them, and their relationship to the teachings 
of the present day. 

Biedert, Meigs, and Rotch (the Protein Period). — Modem 
infant feeding may be said to have started with Philip Biedert's 
inaugural dissertation in 1869. Previous to this time but little 
scientific investigation had been produced in connection with 
it; the little that was known was almost entirely empirical and 
the results of artificial feeding were uniformly bad. Biedert's 
monograph of 64 pages is entitled ^'Investigations Concerning the 
Differences Between Human Milk and Cow's Milk." Previous 
to his time there were on record many analyses of cow's milk, 
but few of human, and the figures varied so widely that it was 
quite certain that but few of them could be correct. 

Cow's milk was supposed to contain about 5 per cent, of 
casein, hxmian milk, 4 per cent. Biedert started with the central 
idea that in order to have a rational basis for the artificial feed- 
ing of infants it was necessary to know the exact composition 
of human milk, the baby's natural food, and then to imitate this 
as closely as possible in the artificial mixture. He showed by 
many analyses that the amount of casein in htunan milk was 
very much less than that in cow's milk, about 2 per cent., he 
believed. He also laid especial stress on the fact that cow's 
milk when treated with acid formed large tough curds, and that 
human milk formed very small soft curds. ■• This was due, he 
said, not only to the fact that there was much less casein in 



126 PRACTICAL INFANT FEEDING 

human milk than in cow's, but also that the casein was different 
qualitatively; cow casein was an entirely different substance 
from human casein. He called all the protein of milk casein, 
and did not know that lactalbumin was also present; with him 
"casein'^ and "protein" are synonymous terms. His two basic 
conceptions: that the protein of human milk is less than half 
that of cow's milk and that the proteins are of different quality 
were fundamentally correct, and were of epoch making impor- 
tance. We shall find that for many years thought in infant 
feeding was greatly influenced by them. He believed that the 
ratio of fat to casein in human milk was as 3.5 to 2 — that in 
cow's milk it was as 4 to 5. The more fat there was in relation 
to the amount of casein present, the more likely was there to 
be a soft curd; this was the reason that the curd of human milk 
was soft and small, and the curd of cow's milk was hard and 
large. Also, he thought that a certain amount of protein was 
necessary to hold the fat in emulsion and facilitate digestion; 
thus we see the beginnings of the idea of the importance of the 
ratio between the food elements. 

Biedert wrote many articles after his first one, and in 1880 
the first edition of his text-book appeared, going through four 
editions, the last in 1900. His central idea was the indigesti- 
bility of the cow casein, and his methods of feeding were all 
based on this. He believed that a mixture should be made in 
which the amount of casein should be reduced considerably 
below that in human milk (to 1 or 1.50 per cent.) and that the 
ordinary milk and water dilutions then in use did not accomplish 
this. In order to raise the nutritional value of the food and 
also to aid in the digestion of the curd, he used dilutions of 
cream or mixtures of whey and cream. In his cream dilutions 
there was a ratio of fat to casein as of 2.5 to 1, which he thought 
was the most favorable one for the proper digestion of the 
casein. The cream mixture usually had sugar added up to about 
5 per cent. 

Besides his regular cream dilutions he developed his famous 
"cream conserve," a thick paste which would keep for a con- 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 27 

siderable period, and which needed simple dilution with water 
before using. This was made from casein, butter, milk, and 
cane-sugar, and the salts of milk. When diluted, according to 
his directions, it contained about 2.50 per cent, fat, 4 per 
cent, sugar, 1 per cent, protein, and 0.20 per cent, salts. He 
recommended this for use only when fresh milk could not be 
obtained, and was always a vigorous advocate of mixtures 
made from fresh, clean milk. He attacked especially the various 
condensed milk mixtures and proprietary foods which had begun 
to spring up, and insisted that nothing could ever take the 
place of fresh cow's milk. Most of his writings are concerned 
with the chemical differences between human milk and cow's 
milk and the proper mixtures to feed to normal babies. 

In the first edition of his text-book there are 377 pages, 
321 of which are devoted to these subjects, and only 56 to patho- 
logic conditions, nor did he attempt any special classification 
of digestive disturbances. He believed that most digestive 
troubles were due to the casein curd, he denied the good of the 
gruel and nulk dilutions in general use, and advised strongly 
against feeding starch to small babies. The sugar, he thought, 
was practically harmless and did not recognize any particular 
type of indigestion caused by it. He found, however, that 
if too much fat was fed diarrhea resulted in certain babies, 
and that in these cases the fat might be as much as 50 per cent, 
of the dried stool. He looked at these stools microscopically 
and mentions the presence of an excess of fat droplets. The 
condition was, he said, probably due to a duodenal catarrh, 
which hindered fat absorption. He also described very dry 
white stools containing an excessive amount of fat, and thought 
they were due to a lack of bile secretions ("soap stools"). He 
believed that failure of fat absorption might have considerable 
importance in causing infantile atrophy, but that in acute 
disturbances the casein was more important. 

Biedert was a scholar, a shrewd observer, a clear writer, 
and his ideas influenced the trend of thought in infant feeding 
for twenty years or more. 



128 PRACTICAL INFANT FEEDING 

Developments in America. Influence of Biedert. — In 1880 
Dr. John Forsyth Meigs of Philadelphia was the most successful 
and most widely known feeder of infants in America. His 
methods were largely empirical, but he got better results than 
had ever before been obtained. About this time he asked his 
son, Dr. Arthur V. Meigs, to make for him some analysis of 
condensed milk. This led the younger Meigs to investigate 
the composition of breast milk, to which he devoted a great 
deal of time, being interested in it up to the time of his death 
in 1911. 

Meigs states his fundamental ideas as follows: "There are 
but two possible methods in endeavoring to reach a conclusion 
about what is right to feed babies, the one purely empiric; 
to experiment with various foods until the best is found; and 
the other by analysis to learn as nearly as possible what human 
milk is, which we all know to be the most perfect food for infants, 
and then to make an imitation of it." . 

In 1882 he made the statement, following much experimental 
work, that human milk never contained more than 1 per cent, 
of casein, and this statement may be said to be at the bottom 
of most of his ideas on feeding. This was about half Biedert's 
figure for the amount of casein present in human milk. Inas- 
much as this is the figure for human milk, said Meigs, in artificial 
feeding more than 1 per cent, of casein should never be in the 
cow's milk mixture offered to the baby. In making a food for 
babies two matters should be considered: the constituents 
must be in the same relative proportions as they are in himaan 
milk, and they must be in a medium which shall be as human 
milk is, alkaline. Furthermore, it is a great mistake to keep 
changing a baby's food in the early months; the baby should 
be started on a food which shall imitate breast milk and this 
should be fed to him without change in strength until he is 
eight or nine months old. He can take as much of it in amount 
as he desires, however. Meigs gives the following directions 
for preparing this food: "One quart of whole milk is put into 
a pot or a high pitcher and allowed to stand three hours; then 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 29 

one pint is poured from this. When the child is to be fed there 
are taken of this weak cream 3 tablespoonfuls; of lime-water, 2 
tablespoonfuls; of sugar- water, 3 tablespoonfuls. This makes 4 
oimces of food. Sugar-water is made by dissolving 18 drams 
of lactose in 1 pint of water. This mixture contains about 4 per 
cent, fat, 7 per cent, sugar, and 1 per cent, protein — ^according 
to Meigs an exact imitation of mother's milk. He fed this to 
babies of all sizes and ages, in all stages of malnutrition. His 
results in hospital practice were rather disappointing, he says, 
and a good many of his babies died, but in private practice the 
results were most gratifying. 

In 1885 appeared his little book, ^'Milk Analysis and Infant 
Feeding," most of which he devoted to a technical discussion 
of his methods of milk analysis, and very little to practical 
feeding. 

Meigs summarizes his principles as follows: "The end to be 
striven for in order that a more general success may be attained 
in the artificial feeding of infants is to diffuse more widely and 
to make common property of the knowledge of the small amount 
of casein in human as compared with cow's milk, and that, in 
addition to the dilution which is necessary to reduce the amount 
of this constituent, we must use in proper proportions cream, 
sugar, and lime-water." 

Meigs' influence was felt all over the country and his ideas 
were widely followed. He had worked along the same lines 
as his predecessor, Biedert, but had added to his work in that 
he came nearer to the actual amount of casein in human milk, 
and devised a more exact formula to be used in the imitation 
of the baby's natural food. 

Rotch. — ^About 1887 Dr. Thomas Rotch of Boston began to be 
interested in infant feeding. He was well acquainted with the 
literature of the day, and was influenced very largely by the teach- 
ings of Biedert. About the time that Meigs was doing his work 
in Philadelphia, Rotch began to study various infant foods. On 
his service at the Infants' Hospital the best results were being 
obtained with condensed milk. This led him to make an analysis 



130 PRACTICAL INFANT FEEDING 

of the condensed milk mixtures that were being fed, and he 
found that most of them contained very close to 1 per cent, 
of casein. From this he argued that 1 per cent, of casein was 
probably the best amount to use, so he turned to Meigs' mixture, 
and gave it a thorough trial. He soon began to see, however, 
that it had its limitations. 

He said, "We began to appreciate that the infants' idio- 
syncrasy was not for any one of the especial combinations 
usually found in human milk, such as high or low total solids, 
or in other words, a strong or a weak mixture, but that any 
one of the various constituents, according as it was in high 
or low percentage, might be the cause of what was represented 
by the especial idiosyncrasy, and thus we arrived at the con- 
clusion that in a multitude of variations and degrees the human 
infant may have an especial idiosyncrasy for a high or low per- 
centage of any one of the food-stuffs or for any combination 
of them. Resulting from this we deduced that to obtain a suc- 
cessful feeding and nutrition for infants we must be able to 
prepare an almost innumerable number of foods, varying in 
the percentage of any one of their ingredients, and in the combi- 
nations of these percentages. Percentage feeding is the varia- 
tion of the individual food elements so that we can give various 
babies the percentages of these elements which are adapted 
to their special digestions." 

These were revolutionary ideas and epoch making. Rotch 
cast down at a blow the teachings of the day, that human milk 
must be imitated, and the same mixture fed to all babies. To 
him we owe the birth of the idea of individualization and varia- 
tion. He looked upon digestive and nutritional disturbances 
as being caused by elements in the diet rather than by the diet 
as a whole, and emphasized strongly the necessity of thinking 
of the food in terms of its elements. 

He followed Biedert in the belief that the casein was the 
cause of more digestive troubles than any other food element, 
and recommended feeding it in very small amounts to young 
babies especially — smaller even than Biedert had used. The 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 131 

fat he regarded as secondary to the casein in importance; the 
sugar he thought least important of all. He devised the gravity 
cream and skimmed milk method of modification, which allows 
of great elasticity in the preparation of milk formulae, and 
almost any ratio between the various food elements that is 
desired. He started milk laboratories in 1891 where the food 
was prepared exactly according to the doctor's prescription 
and delivered to the home ready for use. He insisted upon 
the necessity of thinking in percentages, and the physician's 
knowing as accurately as possible what is in the mixture that is 
being fed to a baby. He believed that very small variations 
in the percentage of the elements in the food were of very great 
significance. He wrote many papers of importance, and for 
long was regarded as the greatest American authority on infant 
feeding. 

Retrospect of Biedert, Meigs, and Rotch. — To Biedert 
we owe the first really important scientific investigations in 
infant feeding, and the proving that human milk and cow's 
milk are very dissimilar in composition, especially as regards 
their casein content. To Meigs we owe a more accurate analysis 
of human milk, and the wide-spread diffusion of his own and of 
Biedert's ideas in America. To Rotch we owe the great prin- 
ciple of individualization, the new conception that it is not the 
food as a whole, but its elements that must be considered. 
Much of the teachings of these men, in the light of our present 
knowledge, does not seem to be, and is probably not, correct, 
but they may be regarded, however, as three of the great pi- 
oneers in infant feeding. Biedert, Meigs, and Rotch devoted 
most of their time to the study of what to feed to the baby; 
their classifications of digestive disturbances were quite secondary 
and relatively unimportant. They did very little regarding 
the physiologic, bacterial, and chemical processes within the 
baby's body; they studied his food rather than himself. The 
next four men that we have to discuss— Widerhofer, Escherich, 
Czemy, and Finkelstein— studied the baby primarily and his 
food secondarily. 



132 PRACTICAL INFANT FEEDING 

Widerhofer, of Vienna, was essentially a pathologist. Vien- 
nese medical thought in his day was largely influenced by the 
studies of Rokitansky, the greatest student of gross pathology. 
It was the age of anatomic pathology: Rokitansky in Vienna 
and Virchow in Berlin were the two greatest pathologists in 
the world, and their influence was felt everywhere. In every 
branch of medicine changes in anatomic structure, both gross 
and microscopic, were made the basis of classification. It was 
natural for students of infant feeding to apply these principles 
to their work. They attempted to find for every clinical pic- 
ture anatomic changes in the organism, and Widerhofer's classi- 
fication is almost entirely an anatomic one. In Gerhardt's 
Handbook of Diseases of Children, published in 1880, he writes 
a very complete chapter on gastro-intestinal disease in babies, 
from the standpoint of a pathologist. He recognizes innumer- 
able pathologic conditions, each of which he believes has a cor- 
responding clinical picture. 

Some of his main divisions are as follows: 

1. Acute gastritis. 

2. Chronic gastritis. 

3. Dilatation of the stomach. 

4. Toxic gastritis. 

5. Helena. 

6. Dyspepsia. 

7. Enteralgia. 

8. Acute and chronic enterocatarrh. 

9. Follicular enteritis. 

10. Membranous enteritis. 

11. Croupous and diphtheric processes. 

12. Syphilitic enteritis. 

13. Amyloid degeneration. 

14. Cholera infantum. 

Such a classification as this is very unsatisfactory, as it 
does not sufficiently take into account the processes which have 
produced the pathologic picture. Furthermore, in many of 
the severest types of gastro-intestinal disturbance in babies 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 33 

there are no pathologic lesions that can be demonstrated, either 
in gross or by the microscope. The changes are largely of func- 
tion rather than of structure. Widerhofer^s classification lasted 
some time, however, and traces of it are still to be seen in several 
modem text-books. Most authorities are agreed, however, 
that the viewpoint of anatomic pathology is not the best one 
to adopt in considering these disturbances. 

Escherich. — No consideration of the development of infant 
feeding would be complete without reviewing the work of 
Theodore Escherich, although he proposed no new system of 
feeding or of classification. In his day (1886) the science of 
bacteriology was in its infancy, and he was the first to study 
carefully the bacteria in the infant's intestine, and to show the 
significance that they had in the normal and abnormal intestinal 
processes and their relation to food in the intestines. He in- 
vestigated the normal intestinal flora, and showed that it was 
of two sorts, the fermentative and putrefactive. He showed 
how the bacteria are necessary for the normal functions of 
digestion, and how they may cause trouble. He was the first 
to see clearly that there are two processes going on in the intes- 
tine: putrefaction of protein and fermentation of carbohydrate, 
and he laid down the great principle that the tj^es of bacteria 
that exist in the intestine are dependent upon the kinds of food 
fed. That high carbohydrate feeding favors the growth of one 
group of bacteria, that high protein feeding favors the growth 
of another group, and that if one type predominates and if the 
excessive breaking down of either carbohydrate or protein 
results, the baby gets into trouble. He recognized the fact 
that when carbohydrate fermentation exists carbohydrate 
should be withdrawn from the diet, and protein substituted, 
to change the type of intestinal flora, and vice versa. This is a 
fundamental principle which cannot be neglected in infant 
feeding. Indeed, I do not believe it is exaggerating to say that 
in dealing with abnormal intestinal processes it is the most 
important principle of all, and nobody can feed babies suc- 
cessfully without taking it into consideration. Bacterial proc- 



134 PRACTICAL INFANT FEEDING 

esses in the intestine, and their relationship to the food supply 
can never be separated from questions of practical infant feed- 
ing, either normal or abnormal. In Escherich's own words, 
"The fact that through designed changes in the food supply 
the character of the bacterial vegetation, and all the processes 
that go with it, can be altered, opens to us a broad and remunera- 
tive perspective, and in order to apply our knowledge of intestinal 
bacteriology practically the first and most important thing is a 
thorough study of bacterial processes in the normal intestine. 
May the views put forth here not be without practical value 
in the treatment of that murderous pestilence of the first year 
of life — diarrhea." 

Czerny and Keller (the Fat Period; About 1900). — Previous 
to Czerny, as we have seen, much had been accomplished in 
the study of the baby's food, of intestinal bacteria, and of the 
pathology of the intestine; attention had been focused either 
on the food before it was given to the baby, or on the digestive 
processes in the bowel; not enough had been given to a con- 
sideration of the baby as a whole, and the effect of the different 
food elements in normal and abnormal conditions upon the 
general metabolism. It remained for Czerny to take a broader 
view, to suggest the term "disturbances of nutrition" instead 
of "gastro-intestinal diseases," and to follow carefully the 
etiologic influence of the various food elements in causing 
these disturbances. "A study of the general metabolism allows 
us to follow the fate of the food-stuffs after they have passed 
through the digestive tract and the influence of unsuitable 
nourishment upon the whole organism of the infant. Metabolic 
studies do away with empirical methods of feeding." 

Czerny and Keller's monumental text-book on infant nu- 
trition appeared in several parts, the first part coming out in 
1906. It is really a marvelous book, showing a broad knowledge 
and a great power of putting together facts and theories to 
make a harmonious whole. 

Czerny and Keller's classification of nutritional disturbances 
is an etiologic one, and was undoubtedly the best that had 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 135 

appeared up to that time. They divided nutritional disturbances 
into three broad groups: (1) from food, (2) from infection, 
(3) from constitution. 

In the first group comes: (1) fat injury, (2) starch injury, 
(3) gelatin injury, (4) scurvy. 

They describe with great clearness the picture of fat injury 
(Fettnahrschaden) and consider it one of the most important 
of all food injuries. It arises from overfeeding with fat, is evi- 
denced by constipation, pallor, loss of turgor, and failure to 
gain. They consider fat the most important of all the food 
elements in causing nutritional disturbance. 

Starch injury (Mehlnahrschaden) comes from a one-sided 
starch diet in the first few weeks of life especially. The baby 
is much emaciated from lack of nourishment. He has had just 
enough starch barely to keep him alive, but no more, and his 
body cells are dying from lack of salts and protein. Thus we 
see the results of the food injury extending beyond the intestine 
and affecting every cell in the body; a true metabolic disease is 
present, and not a mere "indigestion." 

Czerny also attacked the old supposition that protein was 
the most important cause of digestive troubles. He believed 
it did practically no harm, and did not recognize any such thing 
as protein injury in his group of food injuries. This was revolu- 
tionary, as previous to him attention had been focused on the 
protein, and all the attempts in milk modification had one 
particular end in view, to make it of easy digestion. He says, 
"There is no single symptom which can show us injury to the 
infant through protein, and from the standpoint of the clinician 
it is impossible to speak of a protein injury. It is possible that 
with abnormal flora in the intestine, putrefaction of the casein 
might occur. It is, however, as yet unknown whether or not 
this actually does happen; and, furthermore, if it should occur, 
whether or not it has anything to do with nutritional disturb- 
ances. In overfeeding with milk, in our experiences, a fat injury, 
and not a protein injury, occurs. Overfeeding with protein 
is hardly possible; it is much more likely that in an artificially 



136 PRACTICAL INFANT FEEDING 

fed baby there should be protein underfeeding. We cannot 
take into consideration a disturbance of nutrition from protein/' 

Disturbances of nutrition from infection include all condi- 
tions which might be caused by bacteria or their products: 
(1) Infection of the food before it enters the body in such a 
way that toxic products are formed in it. (2) Infection of the 
food in the intestine. (3) Infection of the intestinal mucosa 
itself. Alimentary intoxication is a condition in which the 
symptoms are caused by the toxic products of destroyed food; 
in enteral and parenteral infections the trouble is caused by 
the bacteria themselves attacking the body; in the former 
group by infecting the intestinal wall; in the latter group by 
infecting other parts of the body and causing gastro-intestinal 
and nutritional disturbances secondarily. There are two t5^es 
of alimentary intoxication: one in which chiefly sugar is being 
decomposed; one in which the fat is. Fever in these conditions 
means an injured intestinal wall which makes it permeable 
for bacteria or their toxins, and very small injuries to the intesti- 
nal wall may allow this. The acids from fat or from carbo- 
hydrate decomposition are the starters of the trouble in alimen- 
tary intoxication. These may be introduced in spoiled milk 
or may arise in the gastro-enteric tract from bacterial decom- 
position of food. The symptoms of intoxication have many 
causes, of which only a part are as yet known. It can be assumed 
as true that a part of the symptoms are caused through water 
and salt loss, another through the absorption into the body of 
toxic material from the intestine which could not normally 
pass the intestinal wall, and finally, acidosis must be taken into 
consideration. Special toxins have as yet not been discovered. 
Special toxins are not necessary, however, to explain the clinical 
picture, as nearly all the symptoms are dependent upon dis- 
turbances of the intermediary metabolism which are brought 
about by the pathologic processes in the digestive tract. 

As to milk modification, Czerny recommends simple milk 
dilutions with addition of carbohydrate — one-third milk, two- 
thirds water for a baby in the first few weeks; then one-half 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING I37 

milk, one-half water; later, two-thirds milk, one-third water, 
and finally, about the eleventh month, whole milk. He does 
not believe in the use of cream in any way, as it is likely to 
cause fat injury. 

We owe to Czerny the first really adequate study of the 
nutritional disturbances, and the most comprehensive classi- 
fication of them that had yet appeared. 

Finkelstein. — The teachings of Finkelstein and his co- 
workers, Langstein and Meyer, began to come into prominence 
about 1907, and from then up to the present time have received 
a great deal of attention. Finkelstein's chief contributions 
may be summed up in four phrases: sugar, salts, clinical classi- 
fication, and protein milk. Sugar had been, before his day, 
comparatively neglected as a source of digestive and nutritional 
disturbances; he makes it the cause of most of them. He studied 
carefully sugar fermentation in its different degrees, and the 
results of sugar fermentation, both immediate and remote. 
Sugar fermentation can be brought about in many different 
ways, but it is most likely to ferment in a medium which is rich 
in whey salts, particularly sodium salts. It is the whey salts 
of cow's milk which are injurious, and not the protein. The 
whey salts depress the antibacterial function of the cells of the 
small intestine and thus allow too profuse bacterial growth 
and consequent fermentation of the sugar. The intestinal 
mucosa is impaired functionally by the acids which are formed 
from sugar fermentation, and this functional injury allows the 
salts and unaltered lactose to pass through it into the general 
circulation. Finkelstein at first thought that the lactose was 
the cause of the fever and symptoms of intoxication which 
occur in some of the more severe cases of sugar fermentation, 
but later changed this view, and came to regard the salts as the 
cause of fever. Bacteria and bacterial toxins he does not con- 
sider important, except as they are concerned in the original 
fermentation. His new and startling ideas concerning the salts 
have caused a good deal of discussion, and have stimulated 
much research, some of which is in accord with his views, some 



138 PRACTICAL INFANT FEEDING 

of which is not. Protein never does any harnij and fat is harm- 
ful only when there is a primary sugar injury; sugar is the one 
particular thing that causes trouble for babies. Thus we see 
that every food element in its turn has been considered the 
chief offender — with Biedert, Rotch, and Meigs the protein, 
with Czerny the fat, and lastly, with Finkelstein, the sugar and 
the salts. 

Finkelstein's classification of nutritional disturbances is like- 
wise different from anything that preceded it. He sees these 
conditions with entirely new eyes, and builds up a most in- 
genious edifice in his classification and treatment. His classi- 
fication is purely cHnical; he recognized and studied carefully 
certain conditions that babies get into through errors in digestion 
or nutrition; the etiology of those conditions is a secondary 
consideration. He says, "An etiologic diagnosis I hold to be 
practically impossible, and if it were possible — ^not desirable. 
How little, for example, does the diagnosis 'nutritional disturb- 
ance from infection' mean, when it remains in the dark where 
the origin of the condition Hes, whether from secondary dys- 
peptic fermentation or other causes. It is best to discard all 
etiologic nomenclature and to adopt the clinical; it is desir- 
able for the physician to be able to say what sort of child he 
has before him and how this child will react to definite dietetic 
influences." He admits himself that his classification is by no 
means perfect, and doubts whether there ever can be an abso- 
lutely satisfactory classification, as many of the various disturb- 
ances shade into one another so closely that it is impossible 
to separate them thoroughly. To each food of a certain com- 
position there belongs a certain type of disturbance, and there 
must be as many types of disturbances as there are combinations 
of food elements. 

His four main clinical groups are as follows: (1) Disturbed 
balance; (2) dyspepsia; (3) intoxication; (4) decomposition. 
By disturbed balance he means especially the fat injury of 
Czerny. A baby has previously done well despite adequate 
or overadequate caloric intake, does not gain, or may actually 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING I39 

lose. Instead of a gain of weight resulting from an increase of 
food, a loss is likely to result (the "paradoxic" reaction). The 
food which brings about this disturbance is usually a food rich 
in fat and protein and relatively poor in carbohydrate; accord- 
ing to Czerny, overfeeding with milk; according to Finkelstein, 
underfeeding with carbohydrate. His principles of treatment 
are essentially the same as those of Czerny; reducing the amount 
of milk and adding carbohydrate in the form of maltose and 
starch. 

2. Dyspepsia is the milder form of sugar fermentation. 
In this condition the process is locahzed in the intestinal tract, 
the loss of weight is not large and there are no symptoms of 
intoxication; the baby, as a whole, does not suffer, nor are there 
serious symptoms unless the condition is untreated or treated 
wrongly. Dyspepsia is Hkely to arise from food rich in sugar 
and whey salts ; is favorably influenced by a food low in sugar 
and high in protein. 

3. Intoxication represents a severe metabolic disturbance. 
It may have started as a dyspepsia, or may be engrafted on to 
a decomposition. The process here is not localized in the intes- 
tine, the whole organism suffers ; the child's body is in a state of 
"metabolic bankruptcy," there is chaos where there should be 
order. The temperature is high and the baby's general condi- 
tion bad. The baby is losing nitrogen, water, and salts, and 
there is likely to be considerable acidosis present. The fever 
and most of the untoward symptoms are caused by the whey 
salts, which have gone through the unhealthy intestinal mucosa 
into the general circulation. The prognosis is grave. This is 
the condition which Czerny also describes under the head of 
alimentary intoxication, although he does not believe it is due 
to as specific causes as does Finkelstein. He believes it is a 
resultant of several conditions, many of which we know little 
about. 

4. Decomposition represents what was known to the older 
WTiters as "marasmus," "athrepsia," or "infantile atrophy." 
The condition may arise in a number of ways, either as a result 



I40 PRACTICAL INFANT FEEDING 

of a prolonged ''balance disturbance" or a chronic dyspepsia, 
from an improperly treated intoxication or from prolonged 
underfeeding or improper feeding. The chief thing about 
decomposition is the very low tolerance for food; increasing 
it beyond the limit of tolerance may result either in dyspepsia 
or intoxication. The baby's body is actually decomposing, 
every cell in the body is affected, and the organism is not able 
to assimilate food, even if the digestive processes in the intestine 
were not impaired. 

In order to treat sugar fermentation Finkelstein desired a 
milk preparation very low in sugar and high in protein. The 
purpose is to inhibit sugar fermentation by withdrawing the 
fermenting substance, and to change the bacterial flora of the 
intestine from carbohydrate splitters to protein splitters by 
offering a low carbohydrate and high protein food; to promote 
an alkaline instead of an acid intestinal contents. For this 
purpose he devised the famous "eiweiss" or protein milk, a prepa- 
ration containing fat 2.5 per cent., sugar 1.5 per cent., protein 
3.5 per cent. This was made from equal parts of buttermilk 
and water to which a certain amount of finely sifted milk curd 
has been added. The principle of protein milk feeding is un- 
doubtedly one of the most important advances ever made in 
infant feeding, and pediatricians all over the world have become 
convinced of the worth of Finkelstein's milk or modifications 
of it. Used in the right type of case, it is without question 
remarkably efficacious, but like all good things it has been used 
too much, and in cases in which there is no possible indication 
or need for it. It is not a universal food for all feeding troubles, 
but is merely one more very excellent weapon added to our 
armamentarium. 

As does Czerny, Finkelstein recommends simple dilutions 
of whole milk for feeding most babies, and following him, this 
method of feeding is used by most of those who have studied 
in Germany, It has the advantage of simplicity, but does not 
offer the wide variety of choice in the various combinations of 
the food elements that the older methods of cream dilutions 



DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 141 

and cream and skimmed milk modifications do. In the last ten 
years the influence of Finkelstein has been profound, and it is 
probable that his teachings are followed more than those of 
any other authority at the present time. 

What conclusions may be drawn from this brief resume 
of these various stages in the development of infant feeding? 
Can we believe that we in the present epoch are entirely right, 
and that our predecessors have been wrong? This is hardly 
reasonable, and yet each epoch has been insistent that its ideas 
are the best, which is only natural. Any period in the develop- 
ment of any human activity is at best only an imperfect frag- 
ment, and as research advances many of the old ideas are dis- 
carded, some retained, and some modified. Any period in the 
development of any science always owes most of its ideas to 
the thought of those periods which have preceded it. This is 
particularly true of infant feeding. There has been in infant 
feeding no one startling discovery, such as has occurred in most 
other branches of medicine; its progress has been rather in the 
nature of a gradual development, and it is still in the develop- 
mental stage. When we reaKze that most of what we have come 
to believe as true regarding infant feeding has been developed 
in the last fifty years, it is not difficult to grasp what enormous 
changes may take place in the next fifty. We are at present in 
a period — the period of sugar — ^we have gone through the period 
of protein and of fat. As we learn more our present ideas will 
undoubtedly change and the infant feeding of 1950 will prob- 
ably be little like that of 1920. Whatever classification we use, 
whosesoever teachings we adopt, we must realize that there is 
more than one way of looking at the subject. If we adopt 
Rotch's teachings, Finkelstein's need not necessarily be wrong; 
or, if we accept Finkelstein's, Czerny's need not be considered 
erroneous. Rotch's postulate of knowing approximately the 
percentage composition of the food we offer, and expressing 
our milk modifications in terms of percentages of the food ele- 
ments, can perfectly well be combined with the teachings of 
Czerny and of Finkelstein, and should be. 



142 PRACTICAL INFANT FEEDING 

Something has been gained, something has been added to 
the whole, by each of the various periods, and the teachings 
of all these different men are not incompatible. Czerny's classifi- 
cation is excellent, so is Finkelstein's; babies undoubtedly do 
suffer from fat, likewise from sugar. Some things are not sound 
in the teachings of either; these will soon be discarded and the 
good points will remain. Much of Rotch's teachings we do not 
agree with today — but his main principle, that we must have 
some method of feeding which will allow us variation in dealing 
with the individual, some method by which we can express 
accurately and concisely to others what combination of the 
food elements we are feeding to any given baby, will always 
remain. This principle is absolutely sound, and cannot be 
passed over. It is a pity that European students have not 
paid more attention to American methods, and it is rare indeed 
to see a reference to the name of any American author in a 
German text-book. We in America are far ahead of any method 
that Europe has yet produced in the modification of milk. 
European students are far ahead of us in the study of the normal 
and abnormal chemistry of the baby. As I said before, studies 
in this country have dealt chiefly with the baby's food and how 
to prepare it; German studies chiefly concern the baby him- 
self. German methods of milk modification have little elasticity; 
their whole milk mixtures are, in many cases, quite inadequate. 
We can learn much from them, however, concerning abnormal 
processes in the baby, concerning the pathogenesis of the digest- 
ive and nutritional disorders, and we should combine our own 
ideas of milk modification with their ideas of the baby. There 
are too many practitioners in this country who feed blindly; 
they have not the remotest idea of the underlying reasons for 
their procedures, and we can arrive nowhere, no matter how 
carefully our milk modifications are prepared, or our percentages 
calculated, unless we understand the fundamentals of the science 
of nutrition, the digestion and absorption of the food-stuffs, 
their influence upon each other and the influence of the intestinal 
bacteria upon them all. 



. DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 43 

Different sections of the country use different methods and 
look at feeding problems somewhat differently, despite all that 
has been written, ''that we all feed the same.'' We do not all 
feed the same, and probably never will. In the last few years 
many American pediatricians, particularly from the Middle 
West, have studied in German cHnics, have brought home 
the German ideas and have taught them in the medical schools. 
Followers of these methods have been rather incHned to look 
down on the older methods of "percentage feeding," and those 
who have been brought up in the old methods have given in 
many cases Httle heed to the new. The younger disciples of the 
German school have not investigated carefully enough the 
teachings of the older American authorities, nor have many 
of these older American authorities paid much attention to the 
newer German ideas. The two should be combined: German 
chemistry, American milk modification. More good research 
work in problems of infant nutrition is being done in this coun- 
try than ever before, however, and it will undoubtedly be pro- 
ductive of much good. We owe to German investigators most 
of what we know regarding the baby's normal and pathologic 
chemistry; we owe to American investigators most of our knowl- 
edge regarding modifying cow's milk to make a suitable food 
for him. Infant feeding need not necessarily be made abstruse 
and compHcated, but it must not, on the other hand, be made 
too superficial. The practitioner must know his food elements 
and he able to trace them in their progress through the digestive 
tract; he must also have several methods of milk modification at his 
command, so that he can combine these elements in any way he 
desires to meet special indications; the various milk preparations 
and methods of milk modification are the "tools of the frade,^' as 
Dr. Rachford of Cincinnati has said. Whatever we believe about 
the various food elements, we must realize that most of the 
time it is not exclusively one food element that causes trouble; 
it is rather improper combinations of the elements. We may 
be able to feed a baby successfully on a high fat and low protein, 
but as soon as we employ a high protein and high fat we may 



144 PRACTICAL INFANT FEEDING 

begin to get trouble with the fat digestion. Large amounts 
of one element may be handled well by the baby, large amounts 
of two or more elements usually get him into trouble. 

I can conceive of only two reasonable methods of classifica- 
tion, the etiologic and the clinical. Whichever we follow we 
must realize that the other is not necessarily wrong; it is merely 
another way of looking at the same phenomena; a difference 
in nomenclature rather than in actuahty. My personal feeling 
is that the etiologic nomenclature is the more satisfactory, 
despite certain disadvantages; there are many, however, who 
would not agree with this. This nomenclature is advantageous 
in that it makes us think especially of the various elements 
and what they can do to the baby; it is dangerous in that it 
has a tendency to focus itself upon one element to the exclusion 
of the others, and it unquestionably does not describe the 
various conditions in which the baby may be, as well as does 
the clinical nomenclature of Finkelstein. There is no question 
but that at the present time Finkelstein's teachings are influenc- 
ing infant feeding more than those of any other man or group 
of men. Many of his ideas will last, but a good many will un- 
doubtedly be discarded as further progress is made. There 
is no telling what the next generation will bring forth, but 
judging from past history, our ideas concerning infant feeding 
then will bear little resemblance to our ideas now; in such a 
young science there is possibility of infinite change in the next 
few years. The salts and their relationship to the other food 
elements, their influence upon digestion and upon cell metabo- 
lism seem to offer the most fertile field for research and progress. 

Realizing that we have by no means as yet reached the solution 
of the problem, we must be broad minded, must keep away from 
fads, must not focus on one point to the undue exclusion of others, 
must accept the fact that there is more than one way of looking at 
this most interesting subject, be not too assertive and dogmatic 
in our statements, and remember that what is apparently true 
today may be proved false tomorrow. 



CHAPTER YV 
COW»S MILK 

Average Composition. — The following table, from Heine- 
man, shows the average composition of cow's milk, as given 
by different authors : 

Van Slyke. Bobesch. Richmond. Oliver. Fleishmann. 

Per cent. Per cent. Per cent. Per cent. Per cent. 

Water 87.1 87.3 87.1 87.6 87.75 

Fat 3.9 3.6 3.9 3.25 3.40 

Casein 2.5 3.0 3.0 3.40 2.80 

Lactalbumin 0.70 0.60 0.40 0.45 0.70 

Total protein 3.2 3.8 3.4 3.85 3.50 

Lactose 5.1 4.50 4.75 4.55 4.60 

Ash 0.70 0.70 0.75 0.75 0.75 

Total solids 12.9 12.7 12.7 12.4 12.25 



The most common figures used are: 

Fat 3.5 to 4 per cent. 

Lactose 4.50 per cent. 

Protein 3.50 " 

Salts 0.70 



There may be considerable variation in the composition 
of milk from different cows; therefore, it is best in infant feeding 
to use the milk from a mixed herd, the fat standard of which is 
kept close to 4 per cent. Toward the end of the period of lac- 
tation (eighth or ninth month) the total solids, especially the 
fat and protein, may be increased considerably. Dry fodder 
does not further milk flow as well as green fodder, and often a 

^ In the preparation of this chapter I have made extensive use of Heine- 
man's book, "Milk" (W. B. Saunders Co., 1919), especially as regards the 
section on bacteriology, also of Sommerfeld's "Handbuch der Milchkunde," 
Wiesbaden, 1909. 

lo I4S 



146 PRACTICAL INFANT FEEDING 

change from the stable to the pasture in the spring increases 
the total amount of milk, and its content of solids as well. 
Increased exercise and more sunshine also probably partly 
account for this change. 

Reaction. — The reaction of fresh cow's milk is amphoteric, 
that is, it turns red litmus blue and blue Htmus red. On stand- 
ing, the reaction soon becomes acid, owing to the lactic acid 
that is produced from bacterial decomposition of the milk- 
sugar. Cow's milk, as ordinarily used, is, therefore, more acid 
than human milk. 

Physical Properties. — ^The freezing-point of cow's milk is 
from —.54 to —57° C, the boiling-point about 101° C. Its 
specific gravity is from 1.027 to 1.034. It is more opaque than 
human milk, owing to the larger amount of calcium casein 
that it contains. It is likely to be more yellow in color when 
the cows are taking considerable green fodder. This pigment 
is contained in the fat, and is derived from the carotin and 
xanthophyll present in most chlorophyl containing vegetable 
matter. The milk of different animals and, indeed, of different 
cows has different creaming properties. This is probably due 
largely to the size of the fat globules; the cream of a milk with 
large fat globules, such as Jersey milk, rises much more rapidly 
than the cream of a milk with small fat globules, probably due 
to the fact that the emulsion with large globules is not so per- 
fect, and therefore allows them to become separated from the 
rest of the milk more easily. Goat's milk, which has very small 
fat globules (3 to 4.5 microns), does not cream at all, and human 
milk, in which the majority of fat globules are probably smaller 
than those in cow's milk, does not cream as readily as cow's 
milk. Milk which has been boiled is also very slow in creaming, 
and milk which has been ^ 'homogenized" by mechanically 
breaking up the large fat globules into smaller ones does not 
cream at all. The fat globules rise more rapidly in fresh than 
in old milk, and more slowly in cold than in warm milk. 

Fat. — The fat exists in milk in the form of an emul- 
sion of fat globules. They usually measure from 0.0016 to 



cow's MILK 147 

0.01 mm. in diameter, but may vary a good deal in size accord- 
ing to the breed of the cow. Those of Jersey milk are larger 
than those in the milk of any other breed. There is no relation- 
ship, however, between the size of the fat globules and the 
richness of milk. According to Eckles and Shaw there is no 
appreciable difference in the nature of the fat of different breeds, 
except as regards the size of the globules. The amount of fat, 
however, may vary considerably with the breed, as shown in 
the following table by Van Slyke and Publow (cited by Heine- 
man) : 

Breed. Fat percentages. 

Holstein-Friesian 3 . 26 

Ayreshire 3 . 76 

American Holderness 4. 01 

Shorthorn 4. 28 

Devon 4. 89 

Guernsey 5 . 38 

Jersey 5 . 78 

Butter fat is more compKcated in composition than most 
other animal or vegetable fats. It consists chemically of glycerin 
in combination with a number of fatty acids, forming a so- 
called "triglycerid'' or "ester." The acids which are found in 
the fat of cow's milk in combination with glycerin are many^ 
in the following proportions: 

Acids. Percentage. 

Butyric, caproic, caprylic, and capric acids 6.$ 

Myristic, palmitic, and stearic acids 49.46 

Oleic acid 36. 10 

Glycerol 12. 54 

Some of these acids are solids at ordinary temperature, and are 
non-irritating to the digestive tract; some, such as butyric, 
are Kquids, very volatile, and more irritating. The acids in 
butter fat may then be divided into the volatile (irritating) 
and non- volatile (non-irritating) groups. Of the total fatty 
acid content of cow's milk fat about 15 per cent, are of the 
volatile, irritating group (5 to 27 per cent., according to different 



148 PRACTICAL INFANT FEEDING 

observers). Of these volatile acids, butyric is probably the 
most important. This high content in volatile acid may be of 
considerable practical importance in infant feeding, as will be 
seen later. 

Lactose is the sugar found in the milk of all mammals. 
It is a disaccharid, that is, a sugar consisting of two molecules 
of a simpler sugar, or monosaccharid. The amount of lactose 
varies but little in the milk of different cows. The lactose in 
cow^s milk is identical with that in human milk. 

Protein. — ^The proteins in cow's milk are casein, lactalbumin, 
lactoglobulin, and opalisin. The only two that exist in amounts 
sufficient to be of any importance are casein and lactalbumin. 

Casein is a phosphorus-containing protein of complex chemical 
composition. It is insoluble in water and exists in milk in the 
form of a suspension. It does not coagulate on boihng, but is 
easily precipitated by weak acids and by rennin. It is coagu- 
lated in the stomach by the action of the gastric juices into a 
tough leathery curd. 

Lactalbumin belongs to a different group of proteins than 
casein, and is somewhat similar to egg-albumen. It is soluble 
in water, is not coagulated by acids or by rennin, but is coagulable 
by heat at about 72° to 80° C. 

Cow's milk contains about 3 per cent, of casein and 0.50 
per cent, of lactalbimiin. 

Salts. — ^The most striking thing about the ash of cow's 
milk is its high calcium content in the form of insoluble dicalcium 
phosphate. According to Langstein and Meyer^ 1000 gm. of 
cow's milk contain the following: 

K2O 1.77 gm. 

Na20 0.46 gm. 

CaO 1.72 gm. 

MgO 0.20gm. 

Fe203 0. 0004-0. 0007 gm. 

CI 0.82 gm. 

P2O6 2.06-2.43 gm. 

7.55 gm. 
* Sauglingsernahrung und Sauglingsstoffwechsel, Wiesbaden, 1914. 



cow's MILK 149 

According to Bosworth and Van Slyke^ these salts are 
arranged as follows : 

Percentage. 

Sodium chlorid 10. 6 

Potassium chlorid 9.1 

Monopotassium phosphate 12. 7 

Dipotassium phosphate 9.2 

Potassium citrate 5.4 

Dimagnesium phosphate 3.7 

Magnesium citrate 4.0 

Dicalcium phosphate 7.4 

Tricalcium phosphate 8.9 

Calcium citrate 23 . 5 

Calcium oxid (caseinate) 5.1 

In solution are the salts of potassium, sodium, chlorin, 
citric acid, and some of the phosphates, calcium, and magnesium 
salts. The di- and triphosphates are in suspension and do not 
pass through a porcelain filter. 

Ferments. — Cow's milk contains a number of enzymes or 
ferments, proteolytic, carbohydrate splitting, oxidizing, and 
reducing. Little is known about the action of these enzymes, 
or whether they are of any particular value in the nutrition 
of the infant. Their activity is seriously affected by heat at 
70° C. and they are destroyed at 80° C. 

Vitamins. — (See chapter on Scurvy.) 

Cells. — Cow's milk contains moderate numbers of epithelial 
cells and sometimes leukocytes or red blood-corpuscles derived 
from the circulation. If leukocytes are in excess, disease of the 
udder should be suspected. 

The Bacteriology of Milk. — ^The most important sources 
of the bacteria in cow's milk are: 

1. Manure and dirt about the cows. 

2. Dust and dirt in the bam. 

3. Dirty utensils. 

4. Hands of the milker. 

Milk is one of the best of culture-media for bacteria, and 
consequently dirty milking methods favor the growth of an 
1 Jour. Biol. Chem., vol. xxiv, No. 31,916. 



150 PRACTICAL INFANT FEEDING 

eaormous and varied flora. Even with clean milking methods 
it is extremely difficult to keep down bacterial growth within 
reasonable limits. A clean milk suitable for infant feeding 
should contain a maximum of not over 10,000 bacteria per cubic 
centimeter. Ordinary market milk should be kept below 
100,000 per cubic centimeter. Most of the bacteria found in 
milk are saprophytes, and are harmless for adults. This does 
not hold true for babies, however, and milk infected with large 
numbers of saprophytic organisms is probably one of the greatest 
causes of infant mortality that there is. As regards infant feed- 
ing it is not the typhoid bacillus, etc., which may occasionally 
occur in milk that we are especially interested in, but these 
ordinary saprophytic bacteria. They do not attack the baby 
in the sense of invading his tissues, but attack the food in his 
intestines, and either ferment or putrefy it, forming irritating 
end-products which may bring about severe nutritional dis- 
turbance. 

The saprophytic organisms in milk may be classified as 
follows (Heineman) : 

1. Lactic acid bacteria. 

2. Spore-bearing bacteria. 

3. Bacteria causing abnormal conditions in milk (pigmen- 
tation, etc.). 

4. Molds and yeasts. 

1. The lactic acid organisms include three groups — the Bacil- 
lus aerogenes, the Streptococcus lacticus, and the lactobacilli. 

The first two types are practically always present in market 
milk, and are the ones which cause ordinary souring. The 
Streptococcus lacticus is the most important and most frequent 
in occurrence of all the lactic acid products. In nature this 
organism is widely distributed in plants and cultivated lands, 
in dust, manure, or hay. Its occurrence in cow manure explains 
its constant presence in milk. The lactobaciUi are the ones 
chiefly used in the production of sour fermented milk (lactic 
acid milk, Bulgarian mifl^, etc.). There are many varieties, 
but they are all closely related. They are large Gram-positive 



cow S MILK 151 

badlli, and produce large amounts of lactic acid in milk, some- 
times up to 3 per cent. The most important members of the 
group are the Bacillus bulgaricus, B. acidophilus, B. bifidus, 
and Boas-Oppler bacillus. 

2. Spore-bearing Bacteria. — ^Milk practically always contains 
moderate numbers of spore-bearing bacteria. These consist 
of the Bacillus pro tens, members of the hay bacillus group, 
the bacillus of Fliigge, the gas bacillus (Bacillus aerogenes 
capsulatus), and others. Some of these are organisms which 
attack protein and cause putrefaction of the milk. Others 
have the power of producing butyric or propionic acid from 
milk-sugar. The protein-splitting bacteria ("peptonizers") are 
not present in such large numbers as the lactic acid bacilli, 
and their growth, as a rule, is not particularly easy, as they 
are crowded out by the numerous lactic acid bacilli present, 
and also inhibited to a certain extent by the lactic acid which 
is formed. 

3. Bacteria Causing Special Abnormal Conditions in Milk, — 
Certain bacteria may produce pigments which cause color 
changes in milk. Most of the pigments are of no pathologic 
significance. Other bacteria may produce slimy, stringy, or 
ropy milk. Still others may cause a very noticeable bitter taste 
to appear. 

Blue Milk. — ^Blue is the most common abnormal color. 
Bacillus cyanogenes is the most common cause of it, and, accord- 
ing to Weigmann, may be produced by feeding turnips or clover 
mixed with horsetail which contains the characteristic bacillus. 

Red Milk. — ^A red color may occasionally appear in stale 
milk, and is usually due to the Bacillus prodigiosus. 

Slimy and Stringy Milk. — In stringy milk the consistency 
of the milk is changed so that it can be drawn out into threads, 
sometimes to a length of several feet (Heineman). SHmy or 
stringy milk may be caused by certain slime-forming bacteria, 
or by disease of the udder in some cases. Occasionally certain 
strains of the Streptococcus lacticus may produce sHmy milk, 
but the chief cause of it is the Bacillus lactis viscosi. This 



152 PRACTICAL INFANT FEEDING 

organism is found in nature or the surfaces of stagnant pools, 
and cows carry it on their legs after they have been in wading. 
It grows preferably at low temperature, even as low as that of 
an ice-chest, and when it is once introduced into a dairy it is 
very hard to get rid of. 

Bitter milk is caused by the formation of peptones from 
the milk protein by certain peptonizing bacteria (usually cocci) 
which have the power to attack it, or by feeding certain foods 
to the cow, such as lupine, turnips, or cabbages. 

4. Molds and yeasts are present in all milks, and are espe- 
cially noticeable in very old milks. Some of them have the 
power of attacking protein, some carbohydrate. 

The Souring of Milk. — The kind of decomposition that occurs 
in milk depends largely upon the predominating kinds of 
organisms, and the temperature at which it is kept. The 
bacterial flora of milk practically always includes lactic acid 
organisms, and these usually multiply at such a rate as to out- 
strip all others. They attack the milk-sugar and produce lactic 
acid from it. When the degree of acidity becomes sufficient 
the protein is precipitated ("curdling"). The acidity of milk 
does not usually increase until several hours after milking, 
and then the increase is rapid. As the acid increases the growth 
of the proteolytic bacteria is inhibited, and the lactic acid 
organisms multiply at an extraordinary rate, so that soon enough 
acid is produced to restrain the growth of the proteolytic 
bacteria entirely. When the acid content becomes high, molds 
and yeasts, which prefer an acid medium, begin to multiply, 
the molds attack chiefly the protein, and by protein decompo- 
sition the acid is gradually neutralized. By degrees the acid 
disappears entirely, and the proteolytic bacteria, having sur- 
vived as spores, begin to multiply, producing protein cleavage 
products, and a putrid milk results. In some milks the number 
of lactic acid bacteria is very low, and the protein-splitting 
types may obtain an early foothold. In such cases the milk 
putrefies before enough acid is formed to check the putref)dng 
bacteria. 



153 

According to Bos worth and Van Slyke^ the following chem- 
ical changes take place in sour milk : 

1. About 22 per cent, of the milk-sugar is changed by the 
lactic acid bacteria, 88.5 per cent, of this being converted into 
lactic acid. 

2. Citric acid completely disappears from the milk, being 
decomposed into acetic acid and carbon dioxid. 

3. The insoluble inorganic constituents (dicalcium phos- 
phate) of the fresh milk are made soluble by the lactic acid. 

4. The calcium casein present in the fresh milk is changed 
into free protein and precipitated, the calcium forming lactate. 

It has been said that pasteurized milk putrefies instead of 
souring, because the lactic acid bacilli are killed by pasteuriza- 
tion, whereas the spore-bearing peptonizing bacteria are not. 
This has been disproved by Ayers and Johnson,^ who arrived 
at the following conclusions : 

1. Pasteurized milk always sours because of the develop- 
ment of lactic acid bacteria, which on account of their high 
thermal death-point survive pasteurization. The acid develop- 
ment in an efficiently pasteurized milk is about the same as that 
in a clean raw milk. 

2. The relative proportion of the groups of peptonizing and 
lactic acid bacteria is about the same in efficiently pasteurized 
milk as it is in clean raw milk. 

3. The number of peptonizers in a good grade of pasteurized 
milk on the initial count and on succeeding days is approxi- 
mately the same as in clean raw milk under similar temperature 
conditions. 

Milk also may contain a number of true pathogenic organ- 
isms which produce specific diseases. These, as a rule, get 
into the milk either from a diseased cow, from an infected 
milker, or from water used in washing milk-pails or bottles 
(typhoid). 

Streptococci. — The most common causes of pathogenic 

1 Jour. Biochem., 24, 191, March, 1916. 

2 Bureau of Animal Industry, Bull. 126, 1910. 



154 PBACTICAL INFANT FEEDING 

strq)loc6cd in milk are masMMs ("garget") in the cow, or strep- 
tococcic infection of the throat of the milker. 

Mastitis or "garget" is a very common condition. It is an 
inflammation of the udder, either acute or chronic, due in most 
instances to a streptococcus. In certain cases, particularly 
in the early stages, the most careful physical examination of 
the cow may fail to reveal it. Later the inflammatory condi- 
tion becomes evident. It is, therefore, a most insidious condi- 
tion, as despite the most careful precautions a cow in even a 
certified milk herd may have mastitis and pathogenic strepto- 
cocci may have been occurring in the milk for several days 
before anything wrong with the cow is noticed. 

Milk from a cow suffering with mastitis if it contains pus 
may appear thick and yellowish, and after standing a yellowish 
sediment may separate out. The heat-coagulable albumin is 
likely to increase considerably, while the casein diminishes. 
The reaction is likely to be alkahne. The number of leukocytes 
in the sediment of the milk is greatly increased, and a large 
number of leukocytes plus chains of streptococci are important 
points in diagnosing a mastitis milk. The difficulty is that 
practically all market milk contains the Streptococcus lacticus, 
which is an organism non-pathogenic for man or for cows, and 
it may be very difficult indeed even for a competent bacteriologist 
to distinguish between the various types of streptococci and to 
tell which are harmful and which are not. Probably many 
reports of finding the Streptococcus pyogenes in milk from 
apparently healthy udders really mean the presence of Strepto- 
coccus lacticus. 

Not a few epidemics of so-called septic sore throat have 
been traced to a milk supply infected with virulent streptococci 
from a milker with tonsillitis. In some cases an epidemic has 
assumed serious proportions, and fatal generalized strepto- 
coccus sepsis has followed the initial throat infection. In the 
1915 Boston epidemic over 2000 persons were affected. 

Tuberculosis. — Many cows are infected with tuberculosis, 
and the bovine tubercle bacillus is definitely pathogenic for 



155 

man, particularly for young babies and children. The bovine 
bacillus when taken through infected milk is more likely to 
cause glandular and abdominal tuberculosis than any other 
type. According to Pottenger^ about 10 per cent, of all tuber- 
culosis in human beings is due to the bovine bacillus. Heineman 
estimates that probably 10 per cent, of all dairy cows are tuber- 
cular, and Carpenter found in 1910 that of 421 herds in New 
York State tested by him, 302 contained cows reacting to the 
tuberculin test. The total number of cows tested was 9633, 
and of these, 3432 reacted. According to Heineman a con- 
servative estimate might place the market milk infected with 
the tubercle bacillus at from 6 to 8 per cent. This is, in truth, 
a high percentage, but it is probable that many specimens of 
milk contain so few bacilli that they are destroyed in the stomach 
or pass through the digestive tract without doing any harm. 
None the less the danger to babies and young children from 
milk of tubercular cows is a real one, and it is undoubtedly 
true that a considerable number become infected with tuber- 
culosis in this way. 

If the trouble with the infected cow is tuberculosis of the 
udder, the bacilli get into the milk directly from that source 
in large numbers. If the trouble is pulmonary tuberculosis, 
the feces of the cow is probably the chief source of infection, 
as much tubercular material is swallowed, and there is always 
a not inconsiderable amount of cow manure in milk, unless 
the milking is done with the utmost care (see Standards for 
Certified Milk). 

The Tuberculin Test. — This test is of very great value in 
detecting tuberculosis in cows, as it is almost impossible to 
detect it in the early stages by physical examination alone. 
In the later stages the cow develops symptoms such as diarrhea, 
loss of weight, cough, etc. 

This test is usually considered a very accurate one, and 
according to various observers it is stated that it is correct in 
from 95 to 98 per cent, of all cases. The chief trouble with it 
1 Southern Med. Jour., 1915, vii, 935. 



156 PRACTICAL INFANT FEEDING 

is that it does not distinguish between mild and severe forms 
of tuberculosis. A cow with a small tuberculous gland which 
could not by any possibility infect the milk supply is likely to 
give as marked a tuberculin reaction as one which is in an 
advanced stage of pulmonary tuberculosis. After a tubercuhn 
test has been performed a cow, even if tubercular, will not 
react again for a period of about six weeks. This phenomenon 
has been often taken advantage of by unscrupulous dealers, 
who perform tuberculin tests on their cows just before they 
are offered for sale. 

The tuberculin test is usually carried out as follows (Heine- 
man): 

The temperature of the cow is taken during the day every 
two or three hours, and the tuberculin is injected the even- 
ing of the same day. Beginning early the next morning the 
temperature is taken again at regular intervals. The temper- 
atures of the day previous to and that following injections are 
plotted on a chart and the curves compared. If the maximum 
temperature after injection is 2 degrees or more above the 
normal, tuberculosis is indicated. 

Other Diseases Transmitted by Milk. — ^Epidemics of dysen- 
tery, scarlet fever, typhoid fever, and diphtheria have many 
times been traced to infected milk supplies. 

Preservatives in Milk (Formalin). — ^Although many chemical 
preservatives have been used by unscrupulous dealers in order 
to preserve old milk, formalin is by far the most common. 
If present in a dilution of 1 : 10,000 there is a marked restraining 
influence on bacterial growth, and in a dilution of 1 : 40,000 
it also probably prevents it to a certain extent. In this dilution 
there is a question whether it is harmful or not, but while the 
occasional ingestion of small amounts of formalin might do no 
harm, it is conceivable that in long-continued doses it might. 

Detection of Formaldehyd (Hehner's Test). — ^Place 5 c.c. 
of the milk in a test-tube and pour about 3 c.c. of commercial 
concentrated sulphuric acid slowly down the side of the tube 
so that the hquids do not mix. At the junction of the Hquids 



157 

a violet zone appears in the presence of formaldehyd. If pure 

sulphuric acid is used, a few crystals of ferrous sulphate should 

be added to the acid, as iron is a necessary ingredient for this 

test. 

Frozen Milk. — In severe winters milk is often delivered in a 

frozen condition, and mothers are in doubt as to whether it 

should be used. My own opinion is that it should not be used 

if any other can be obtained, as I have seen it apparently cause 

severe vomiting in a few babies. In others it appears to do no 

harm. Mixsell,^ in an excellent article on frozen milk, quoted 

below, says he has personally seen no ill effects from its use, 

but advises against it, as there are so many differences of opinion 

regarding it. The freezing-point of milk is about 55° C. The 

water freezes at first in proximity to the wall of the jar; the 

solids are forced toward the center, where a more concentrated 

solution is formed, which freezes only at lower temperatures. 

The chemical action of freezing on the fat and on the lactose 

is slight; the protein is split into peptones and eventually into 

amino-acids, but this occurs only after a period of two weeks 

or more. Freezing does not destroy the pathogenic bacteria, 

and milk kept very cold does not sour, but turns putrid, because 

the lactic acid bacteria do not grow at low temperature, while 

the putrefying organisms do. Thawed milk is never exactly 

the same as milk which has not been frozen. The natural 

emulsion of fat is never restored after freezing, and the casein 

is likely to appear in flakes rather than in its original colloidal 

condition. If frozen cream is added to coffee the fat of the 

cream does not mix homogeneously, but rises on the surface 

in large oily, yellow globules. The probable reason why milk 

which has been frozen upsets some babies is that the fat is 

rendered more difficult of digestion owing to the breaking up 

of its emulsion. 

CERTIFIED MILK 

The term "certified milk" was first introduced by the late 
Dr. Coit, of Newark, New Jersey, and simply means a clean ^ 
lArch. Ped., vol. xxxvii, No. 5, 1920. 



158 PRACTICAL INFANT FEEDING 

raw milk produced under the most careful conditions, which is 
certified by a medical milk commission to measure up to the 
standards set by the Association of Medical Milk Commissions. 
The production of clean milk is the first and fundamental step 
in infant feeding, and it is so important for the physician to 
understand the conditions under which such milk is produced 
that I have included (copied from Heineman) the more impor- 
tant portions of the rules adopted by the American Association 
of Medical Milk Commissions for the production of certified milk. 

Standards for Certified Milk 

Hygiene of the Dairy. — 1. Pastures ox paddocks to which the 
cows have access shall be free from marshes or stagnant pools, 
crossed by no stream which might become dangerously contami- 
nated, at sufficient distances from offensive conditions to suffer 
no bad effects from them, and shall be free from plants which 
affect the milk deleteriously. 

2. Surroundings of Buildings. — ^The surroundings of all 
buildings shall be kept clean and free from accumulations of 
dirt, rubbish, decayed vegetable or animal matter or animal 
waste, and the stable yard shall be well drained. 

3. Location of Buildings. — Buildings in which certified 
milk is produced and handled shaH be so located as to insure 
proper shelter and good drainage and at sufficient distance 
from other buildings, dusty roads, cultivated and dusty fields, 
and all other possible sources of contamination; provided, in 
the case of unavoidable proximity to dusty roads or fields, the 
exposed side shall be screened with cheese-cloth. 

4. Construction of Stables. — ^The stables shall be constructed 
so as to facilitate the prompt and easy removal of waste products. 
The floors and platforms shall be made of cement or other 
non-absorbent material and the gutters of cement only. The 
floors shall be properly graded and drained, and the manure 
gutters shall be from 6 to 8 inches deep and so placed in relation 
to the platform that all manure will drop into them. 

5. The inside surface of the walls and all interior construe- 



159 

tion shall be smooth, with tight joints, and shall be capable 
of shedding water. The ceiling shall be of smooth material and 
dust-tight. All horizontal and slanting surfaces which might 
harbor dust shall be avoided. 

6. Drinking and Feed Troughs. — Drinking troughs or basins 
shall be drained and cleaned each day, and feed troughs and 
mixing floors shall be kept in a clean and sanitary condition. 

7. Stanchions, when used, shall be constructed of iron pipes 
or hard wood, and throat latches shall be provided to prevent 
the cows from lying down between the time of cleaning and the 
time of milking. 

8. Ventilation. — ^The cow stables shall be provided with 
adequate ventilation either by means of some approved artificial 
device, or by the substitution of cheese-cloth for glass in the 
windows, each cow to be provided with a minimum of 600 cubic 
feet of air space. 

9. Windows. — ^A sufficient number of windows shall be in- 
stalled and so distributed as to provide satisfactory light and 
a maximum of sunshine, 2 feet square of window area to each 
600 cubic feet of air space to represent the minimum. The 
coverings of such windows shall be kept free from dust and 
dirt. 

10. Exclusion of Flies, etc. — All necessary measures should 
be taken to prevent the entrance of flies and other insects and 
rats and other vermin into all the buildings. 

11. Exclusion of Animals from the Herd. — No horses, hogs, 
dogs, or other animals or fowls shall be allowed to come in con- 
tact with the certified herd, either in the stables or elsewhere, 

12. Bedding. — No dusty or moldy hay or straw, bedding 
from horse stalls, or other unclean materials shall be used for 
bedding the cows. Only bedding which is clean, dry, and ab- 
sorbent may be used, preferably shavings or straw. 

13. Cleaning Stable and Disposal of Manure. — Soiled bed- 
ding and manure shall be removed at least twice daily, and the 
floors shall be swept and kept free from refuse. Such cleaning 
shall be done at least one hour before the milking time. Manure, 



l6o PRACTICAL INFANT FEEDING 

when removed, shall be drawn to the field or temporarily stored 
in containers so screened as to exclude flies. Manure shall not 
be even temporarily stored within 300 feet of the barn or dairy- 
building. 

14. Cleaning of Cows. — ^Each cow in the herd shall be groomed 
daily, and no manure, mud, or filth shall be allowed to remain 
upon her during milking; for cleaning, a vacuum apparatus is 
recommended. 

15. Clipping.— "Long hairs shall be clipped from the udder 
and flanks of the cow and from the tail above the brush. The 
hair on the tail shall be cut so that the brush may be well above 
the ground. 

16. Cleaning of Udders. — ^The udders and teats of the cow 
shall be cleaned before milking; they shall be washed with a 
cloth and water, and dry wiped with another clean sterilized 
cloth — a separate cloth for drying each cow. 

17. Feeding. — ^All food-stuffs shall be kept in an apartment 
separate from and not directly communicating with the cow 
barn. They shall be brought into the barn only immediately 
before the feeding hour, which shall follow the milking. 

18. Only those foods shall be used which consist of fresh, 
palatable, or nutritious materials, such as wiU not injure the 
health of the cows or unfavorably affect the taste or character 
of the milk. Any dirty or moldy food or food in a state .of 
decomposition or putrefaction shall not be given. 

19. A well-balanced ration shall be used, and all changes 
of food shall be made slowly. The first feedings of grass, alfalfa, 
ensilage, green corn, or other green feeds shall be given in small 
rations and increased gradually to fuU rations. 

20. Exercise. — ^All dairy cows shall be turned out to exercise 
at least two hours in each twenty-four in suitable weather. 
Exercise yards shall be kept free from manure and other filth. 

21. Washing of Hands. — Conveniently located facilities shall 
be provided for the milkers to wash in before and during milking. 

22. The hands of the milkers shall be thoroughly washed 
with soap, water and brush, and carefully dried on a clean towel 



cow's MILK l6l 

immediately before milking. The hands of the milkers shall 
be rinsed with clean water and carefully dried before milking 
each cow. The practice of moistening the hands with milk is 
forbidden. 

23. Milking Clothes. — Clean overalls, jumper, and cap 
shall be worn during milking. They shall be washed or sterihzed 
each day and used for no other purpose, and when not in use 
they shall be kept in a clean place, protected from dust and dirt. 

24. Things to be Avoided by Milkers.— While engaged about 
the dairy or in handling the milk employees shall not use tobacco 
or intoxicating Kquors. They shall keep their fingers away 
from their noses and mouths, and no milker shall permit his 
hands, fingers, lips, or tongue to come in contact with milk 
intended for sale. 

25. During milking the milkers shall be careful not to touch 
anything but the clean top of the milking stool, the milk pail, 
and the cow's teats. 

26. Milkers are forbidden to spit upon the wails or floors 
of stables, or upon the walls or floors of milk houses, or into 
the water used for cooHng the milk or washing the utensils. 

27. Fore-milk. — The first streams from each teat shall be 
rejected, as this fore-milk contains large numbers of bacteria. 
Such milk shall be collected into a separate vessel and not 
milked on to the floors or into the gutters. The milking shall 
be done rapidly and quietly, and the cows shall be treated kindly. 

28. Milk and Calving Period. — Milk from all cows shall be 
excluded for a period of forty-five days before and seven days 
after parturition. 

29. Bloody and Stringy Milk. — If milk from any cow is 
bloody and stringy or of unnatural appearance, the milk from 
that cow shall be rejected and the cow isolated from the herd 
until the cause of such abnormal appearance has been deter- 
mined and removed, special attention being given in the mean- 
time to the feeding or to possible injuries. If dirt gets into the 
pail, the milk shall be discarded and the pail washed before it is 
used. 



l62 PRACTICAL INFANT FEEDING 

30. Make-Up of Herd. — No cows except those receiving the 
same supervision and care as the certified herd shall be kept 
in the same barn or brought in contact with them. 

31. Employees Other than Milkers. — The requirements for 
milkers, relative to garments and cleaning of hands, shall apply 
to all other persons handling the milk, and children unattended 
by adults shall not be allowed in the dairy nor in the stable 
during milking. 

32. Straining and Strainers. — ^Promptly after the milk is 
drawn it shall be removed from the stable to a clean room and 
then emptied from the milk pail to the can, being strained 
through strainers made of a double layer of finely meshed cheese- 
cloth or absorbent cotton thoroughly sterilized. Several strainers 
shall be provided for each milking in order that they may be 
frequently changed. 

?>2>. Dairy Building. — ^A dairy building shaU be provided 
which shall be located at a distance from the stable and dwelling 
prescribed by the local commission, and there shall be no hog- 
pen, privy, or manure pile at a higher level or within 300 feet 
of it. 

34. The dairy building shall be kept clean and shall not be 
used for purposes other than the handhng and storing of milk 
and milk utensils. It shall be provided with light and ventila- 
tion, and the floors shall be graded and water-tight. 

35. The dairy building shall be well lighted and screened 
and drained through well-trapped pipes. No animals shall be 
allowed therein. No part of the dairy building shall be used 
for dwelling or lodging purposes, and the bottling room shall 
be used for no other purpose than to provide a place for clean 
milk utensils and for handling the milk. During bottHng this 
room shall be entered only by persons employed therein. The 
bottle room shall be kept scrupulously clean and free from 
odors. 

36. Temperature of Milk. — ^Proper cooling to reduce the 
temperature to 45° F. shall be used, and aerators shall be so 
situated that they can be protected from flies, dust, and odors. 



cow's MILK 163 

The milk shall be cooled immediately after being milked, and 
maintained at a temperature between 35° and 45° F. until 
delivered to the consumer. 

37. Sealing of Bottles. — Milk after being cooled and bottled 
shall be immediately sealed in a manner satisfactory to the 
commission, but such seal shall include a sterile hood which 
completely covers the lip of the bottle. 

Zd), Cleaning and Sterilizing of Bottles, — ^The dairy building 
shall be provided with approved apparatus for the cleansing 
and steriHzing of all bottles and utensils used in milk produc- 
tion. All bottles and utensils shall be thoroughly cleaned by 
hot water and sal soda, or equally pure agent, rinsed until the 
cleaning water is thoroughly removed, then exposed to live 
steam or boiling water at least twenty minutes, and then kept 
inverted until used, in a place free from dust and other con- 
taminating materials. 

39. Utensils, — ^All utensils shall be so constructed as to be 
easily cleaned. The milk pail should preferably have an elliptic 
opening 5 by 7 inches in diameter. The cover of this pail should 
be so convex as to make the entire interior of the pail visible 
and accessible for cleaning. The pail shall be made of heavy 
seamless tin, and with seams which are flushed and made smooth 
by solder. Wooden pails, galvanized-iron pails, or pails made of 
rough, porous materials are forbidden. AH utensils used in 
milking shall be kept in good repair. 

40. Water-supply. — ^The entire water-supply shall be abso- 
lutely free from contamination, and shall be sufficient for all 
dairy purposes. It shaU be protected against flood or surface 
drainage and shall be conveniently situated in relation to the 
milk house. 

41. Privies, etc., in Relation to Water-supply. — ^Privies, 
pigpens, manure piles, and all other possible sources of con- 
tamination shall be so situated on the farm as to render impos- 
sible the contamination of the water-supply, and shaU be so 
protected by use of screens and other measures as to prevent 
their becoming breeding ground for flies. 



164 PRACTICAL INFANT FEEDING 

42. Toilet Rooms, — ^Toilet facilities for the milkers shall 
be provided and located outside of the stable or milk house. 
These toilets shall be properly screened, shall be kept clean, 
and shall be accessible to wash basins, water, nail-brush, soap 
and towels, and the milkers shaU be required to wash and dry 
their hands immediately after leaving the toilet room. 

43. Transportation. — In transit the milk packages shall be 
kept free from dust and dirt. The wagon, trays, and crates 
shall be kept scrupulously clean. No bottles shall be collected 
from houses in which communicable diseases prevail, unless a 
separate wagon is used and under conditions prescribed by the 
department of health, and the medical milk commission. 

44. All certified milk shall reach the consumer within thirty 
hours after milking. 

Veterinary Supervision of the Herd. — ^45. Tuberculin Test. 
— ^The herd shall be free from tuberculosis, as shown by the 
proper application of the tuberculin test. The test shall be 
applied in accordance with the rules and regulations of the 
United States Government, and all reactors shall be removed 
immediately from the farm. 

46. No new animals shall be admitted to the herd without 
first having passed a satisfactory tuberculin test, made in accord- 
ance with the rules and regulations mentioned; the tuberculin 
to be obtained and applied only by the official veterinarian of 
the commission. 

47. Immediately following the application of the tuberculin 
test to a herd for the purpose of eHminating tuberculous cattle, 
the cow stable and exercising yards shall be disinfected by the 
veterinary inspector in accordance with the rules and regula- 
tions of the United States Government. 

48. A second tubercuHn test shall follow each primary test 
after an interval of six months, and shall be applied in accordance 
with the rules and regulations mentioned. Thereafter, tuberculin 
tests shall be reapplied annually, but it is recommended that the 
retests be applied semi-annually. 

49. Identification of Cows. — ^Each dairy cow in each of the 



i65 

certified herds shall be labeled or tagged with a number or 
mark which shall permanently identify her. 

50. Herd-hook Record. — Each cow in the herd shall be 
registered in a herd book, which register shall be accurately 
kept so that her entrance and departure from the herd and her 
tuberculin testing can be identified. 

51. A copy of this herd-book record shall be kept in the 
hands of the veterinarian of the medical milk commission under 
which the dairy farm is operating, and the veterinarian shall 
be made responsible for the accuracy of this record. 

52. Dates of Tuberculin Tests. — ^The dates of the annual 
tuberculin tests shall be definitely arranged by the medical 
milk commission, and all of the results of such tests shall be 
recorded by the veterinarian and regularly reported to the 
secretary of the medical milk commission issuing the certificate. 

53. The results of all tuberculin tests shall be kept on iAe 
by each medical milk commission, and a copy of all such tests 
shall be made available to the American Association of Medical 
Milk Commission for statistical purposes. 

54. The proper designated officers of the American Associa- 
tion of Medical Milk Commission should receive copies of 
reports of aU of the annual, semi-annual, and other official 
tuberculin tests which are made and keep copies of the same 
on file and compile them annually for the use of the association. 

55. Disposition of Cows Sick with Diseases Other than Tuber- 
culosis. — Cows having rheumatism, leukorrhea, inflammation 
of the uterus, severe diarrhaea, or disease of the udder, or cows 
that from any other cause may be a menace to the herd shall 
be removed from the herd and placed in a building separate 
from that which may be used for the isolation of cows with 
tuberculosis, unless such building has been properly disinfected 
since it was last used for this purpose. The milk from such 
cows shall not be used nor shall the cows be restored to the 
herd until permission has been given by the veterinary inspector 
after a careful physical examination. 

56. Notification of Veterinary Inspector. — In the event of 



l66 PRACTICAL INFANT FEEDING 

the occurrence of any of the diseases just described between 
the visits of the veterinary inspector, or if at any time a number 
of cows become sick at one time in such a way as to suggest the 
outbreak of a contagious disease or poisom'ng, it shall be the 
duty of the dairyman to withdraw such sickened cattle from 
the herd, to destroy their milk, and to notify the veterinary 
inspector by telegraph or telephone immediately. 

57. Emaciated Cows. — Cows that are emaciated from chronic 
disease or from any cause that in the opinion of the veterinary 
inspector may endanger the quality of the milk, shall be removed 
from the herd. 

Bacteriologic Standards. — 58. Bacterial Counts. — Certified 
milk shall contain less than 10,000 bacteria per cubic centi- 
meter when delivered. In case a count exceeding 10,000 bacteria 
per cubic centimeter is found, daily counts shall be made, and 
if normal counts are not restored within ten days the certificate 
shall be suspended. 

59. Bacterial counts shall be made at least once a week. 

60. Collection of Samples. — ^The samples to be examined 
shall be obtained from milk as offered for sale and shall be 
taken by a representative of the milk commission. The samples 
shall be received in the original packages, in properly iced con- 
tainers and they shall be so kept until examined, so as to limit 
as far as possible changes in their bacterial content. 

61. The fat standard for certified mUk shall be 4 per cent., 
with a permissible range of variation of from 3.5 to 4.5 per cent. 

Methods and Regulations for the Medical Examination of 
Employees, Their Health and Personal Hygiene 

62. A medical officer, known as the attending dairy physi- 
cian, shall be selected by the commission, who should reside 
near the dairy producing certified milk. He shall be a physi- 
cian in good standing and authorized by law to practice medicine; 
he shall be responsible to the commission and subject to its 
direction. In case more than one dairy is under the control 
of the commission and they are in different localities, a separate 



cow's MILK 167 

physician should be designated for employment for the super- 
vision of each dairy. 

63. Before any person shall come on the premises to live 
and remain as an employee, such person, before being engaged 
in milking or the handling of milk, shall be subjected to a com- 
plete physical examination by the attending physician. No 
person shall be employed who has not been vaccinated recently 
or who upon examination is found to have a sore throat, or to 
be su'ffering from any form of tuberculosis, venereal disease, 
conjimctivitis, diarrhaea, dysentery, or who has recently had 
typhoid fever or is proved to be a typhoid carrier, or who has 
any inflammatory disease of the respiratory tract or any suppu- 
rative process or infectious skin eruption, or any disease of an 
infectious or contagious nature, or who has recently been asso- 
ciated with children sick with contagious disease. 

64. In addition to ordinary habits of personal cleanliness 
all milkers shall have well-trimmed hair, wear close-fitting 
caps, and have clean shaven faces. 

65. When the milkers live upon the premises their dormi- 
tories shall be constructed and operated according to plans 
approved by the commission. A separate bed shall be provided 
for each milker and each bed shall be kept supplied with clean 
bedclothes. Proper bathing facihties shall be provided for all 
employees on the dairy premises, preferably a shower-bath, 
and frequent bathing shall be enjoined. 

66. In case the employees Hve on the dairy premises a 
suitable building shall be provided to be used for the isolation 
and quarantine of persons under suspicion of having a contagious 
disease. 

The following plan of construction is recommended: 
The quarantine building and hospital should be one story 
high and contain at least two rooms, each with a capacity of 
about 6000 cubic feet and containing not more than three beds 
each, the rooms to be separated by a closed partition. The 
doors opening into the rooms should be on opposite sides of the 
building and provided with locks. The windows should be 



l68 PRACTICAL INFANT FEEDING 

barred and the sash should be at least 5 feet from the ground 
and constructed for proper ventilation. The walls should be 
of a material which will allow proper disinfection. The floor 
should be of painted or washable wood, preferably of concrete, 
and so constructed that the floor may be flushed and properly 
disinfected. Proper heating, lighting, and ventilating facilities 
should be provided. 

67. In the event of any illness of a suspicious nature the 
attending physician shall inunediately quarantine the suspect, 
notify the health authorities and the secretary of the commis- 
sion, and examine each member of the dairy force, and in every 
inflammatory affection of the nose or throat occurring among 
the employees of the dairy, in addition to carrying out the 
above-mentioned program, the attending physician shall take 
a culture and have it examined at once by a competent bac- 
teriologist approved by the commission. Pending such examina- 
tion, the affected employee or employees shall be quarantined. 

68. It shall be the duty of the secretary, on receiving notice 
of any suspicious or contagious disease at the dairy, at once 
to notify the committee having in charge the medical super- 
vision of employees of the dairy farm upon which such disease 
has developed. On receipt of notice this committee shall assume 
charge of the matter, and shall have power to act for the com- 
mission as its judgment dictates. As soon as possible, there- 
after, the committee shall notify the commission, through its 
secretary, that a special meeting may be called for ultimate 
consideration and action. 

69. When a case of contagious disease is found among the 
employees of a dairy producing certified milk under the control 
of a medical milk commission, such employee shall be at once 
quarantined and as soon as possible removed from the plant, 
and the premises fumigated. 

70. When a case of contagion is found on a certified dairy 
it is advised that a printed notice of the facts shall be sent to 
every householder using the milk, giving in detail the precau- 
tions taken by the dairyman under the direction of the com- 



169 

mission, and it is further advised that all milk produced at such 
dairy shall be heated at 145° F. for forty minutes, or 155° F. 
for thirty minutes, or 167° F. for twenty minutes, and imme- 
diately cooled to 50° F. These facts should also be part of the 
notice, and such heating of the milk should be continued during 
the accepted period of incubation for such contagious disease. 

The following method of fumigation is recommended: 

After all windows and doors are closed and the cracks sealed 
by strips of paper applied with flour paste, and the various 
articles in the room so hung or placed as to be exposed on all 
sides, preparations should be made to generate formaldehyd 
gas by the use of 20 ounces of formaldehyd and 10 ounces of 
permanganate of potash for every 1000 cubic feet of space 
to be disinfected. 

For mixing the formaldehyd and potassium permanganate 
a large galvanized-iron pail or cylinder holding at least 20 
quarts and having a flared top should be used for mixing therein 
20 ounces of formaldehyd and 10 ounces of permanganate. 
A cylinder at least 5 feet high is suggested. The containers 
should be placed about in the rooms and the necessary quantity 
of permanganate weighed and placed in them. The formaldehyd 
solution for each pail should then be measured into a wide- 
mouthed cup and placed by the pail in which it is to be used. 

Although the reaction takes place quickly, by making prepara- 
tions as advised all the pails can be ''set off" promptly by one 
person, since there is nothing to do but to pour the formaldehyd 
solution over the permanganate. The rooms should be kept 
closed for four hours. As there is a slight danger of fire, the 
reaction should be watched through a window or the pails 
placed on a non-inflanmiable surface. 

71. Following a weekly medical inspection of the employees, 
a monthly report shall be submitted to the secretary of the 
medical milk commission on the same recurring date by the 
examining visiting physician. 



170 PRACTICAL INFANT FEEDING 

THE COOKING OF MILK 
In order to reduce the normal bacterial growth in milk and 
to kill pathologic organisms it is heated by one of two methods: 

1. Pasteurization. 

2. Boiling. 

Let us see what is accomplished by each of these methods, 
and what their advantages and disadvantages are as regards 
infant feeding. 

Pasteurization. — In pasteurization the milk is heated to a 
temperature considerably below the boiling-point and is kept 
at that temperature for a period of time. A number of different 
methods are used commercially, but the most common and 
most satisfactory one is known as the "holding" method, where 
the milk is heated to 140° F. (60° C.) and is kept at that tempera- 
ture for twenty minutes. In the home milk can be efi&dently 
pasteurized in an ordinary tin pail. The individual milk bottles 
are put into the pail and water is added so that the bottles will 
be well covered up to the necks. Then the water is heated up 
to 160° F. When this temperature is reached the pail is removed 
from the stove and a heavy blanket is put over it to keep the 
heat in. It is allowed to stand one- half hour; then it is rapidly 
cooled and is put on the ice. Rapid cooling is important after 
pasteurization or boiling, as slow cooling, with the temperature 
of the milk at blood heat for a considerable period of time, 
favors the development of bacteria from the spores which have 
not been killed by the heat. There are a number of very con- 
venient small home pasteurizers on the market, one of the best 
of which is that devised by Freeman. 

What Pasteurization Accomplishes. — By pasteurization the 
vast majority of all organisms except spore bearers are destroyed. 
Especially is it to be noted that pasteurization kills the tubercle 
bacillus, and all the other ordinary pathogenic bacteria found 
in milk. It has been commonly believed that the vitamins are 
not destroyed by pasteurization, but there is some evidence, 
according to Hess, to show that their efficiency may be con- 
siderably impaired, especially if the milk is rather old when 



cow S MILK 171 

it is pasteurized, and if the pasteurization is continued more 
than the ordinary time. (See chapter on Scurvy.) 

Pasteurized milk sours normally, as does imcooked milk, 
owing to the fact that some lactic acid bacteria of high thermal 
death-point practically always survive. Pasteurized milk natur- 
ally keeps longer than unpasteurized milk of the same grade. 
The commercial pasteurization of milk has undoubtedly accom- 
plished much and is a practical necessity for the general milk 
supply of large cities. 

Boiling. — Boiling is usually done in the home in either one 
of two ways: 

Open Boiling in a Saucepan. — By this method the temperature 
of the milk reaches about 101° C. If the chief purpose of boiling 
is to render the casein curd more digestible, this is the best 
method to use, and the milk should be boiled vigorously for 
from three to ^wt minutes. It is very likely to ^'boil over" 
and has to be watched and stirred constantly, so that ordinarily 
it is simpler to employ the second method, which requires 
less attention. 

Boiling in a Double Boiler. — By this method the milk reaches 
a temperature of about 99° C. and does not actually "boil." 
For all practical purposes, however, it is "boiled milk." The 
bacterial content is reduced as efficiently as it is by the open 
method, but boiling in a double boiler is not so efficient in making 
a soft curd. The water is put into the double boiler cold, and 
the milk allowed to cook for ten or fifteen minutes after the 
water in the outer vessel has come to a boil. It is then 
taken from the stove, and the outer vessel filled with several 
dianges of cold water so that the milk may cool as rapidly as 
possible. 

Changes Produced by Boiling. — By boiling aU bacteria are 
destroyed except the most hardy spores. When milk is boiled 
a thin scum forms on the surface of the milk. This is partly 
due to coagulated proteias (lactalbumin, lactoglobulin) and 
partly to drying of the milk constituents on the surface. This 
scum consists chemically of 



172 PRACTICAL INFANT FEEDING 

Fatty matter 45.42 per cent. 

Casein and albuminoid material 50.86 " 

Ash 3.72 « (Rosenau) 

Fat.— The emulsion of fat is partly broken up, and there is 
coalescence of some of the fat globules. Cream does not rise 
as well on boiled milk as it does on raw or on pasteurized milk. 

Sugar. — ^There is a caramelization or charring of a certain 
amount of the lactose. This does not usually take place to any 
extent below 120° C, which is never reached in ordinary boiling. 

Protein. — The lactalbumin and lactoglobulin are coagulated. 
This begins at about 75° C. 

The casein is rendered less easy of coagulation by rennin, 
and a soft and flocculent curd is formed in the stomach instead 
of a hard, tough curd. 

Salts. — There is a precipitation in insoluble form of a por- 
tion of the calcium and magnesium salts, and a considerable 
part of the phosphates. According to Soldner^ (quoted by Lane- 
Clayton) about a sixth of the total calcium content is precipi- 
tated in this way, which is not enough to greatly reduce the 
available calcium to any great extent, although, according to 
Bosworth,2 it is precipitated in a form (insoluble calcium phos- 
phate) which cannot be absorbed by the baby. 

Taste. — ^A characteristic "cooked" taste and smell devel- 
ops, which is probably due to the liberation of minute quantities 
of hydrogen sulphid. 

Vitamins and Ferments. — Ferments are destroyed by 
boiling, as are true bacterial toxins. There may be, however, 
other toxic decomposition products present in stale milk, which 
are not destroyed by boiling. The antiscorbutic vitamin is 
rendered less efficient, and probably destroyed by prolonged 
boiling. The other two vitamins are apparently not affected. 

Souring. — Boiled milk ordinarily does not sour. It putre- 
fies, owing to the fact that all of the lactic acid forming bacteria 
have been destroyed. 

1 Landw. Versuchs, 1888, p. 35. 

2 Personal communication. 



cow's MILK 173 

The advantages of boiled milk are obvious: 

1. By a very simple procedure the milk is rendered practically 
sterile, and the dangers which go with a bacterially contaminated 
milk are at once done away with. This is of tremendous impor- 
tance, and if physicians living in places where the milk supply 
is doubtful would only realize this they would not need to turn 
to condensed milk and proprietary foods in the summertime 
as so many do. 

2. The casein curd is rendered soft and flocculent, so that 
the chances of disturbing the baby's digestion from difficulty 
of casein digestion is greatly diminished, and a greater concen- 
tration of milk can be taken than would be the case with raw 
milk. 

The main disadvantages that have been attributed to boiled 
milk are these: 

1. The antiscorbutic vitamin is impaired in efficiency, thus 
predisposing to scurvy. 

2. It is possible that the calcium salts are rendered less 
available in boiled milk than in raw. 

3. Boiled milk is somewhat more constipating than raw 
milk. 

4. It has been said that boiled milk is less nutritious than 
raw milk. 

5. It has been said that babies fed on boiled milk are more 
likely to develop rickets than those fed on raw milk. 

6. The ferments are destroyed by boiling. 

Let us consider critically how real these "disadvantages" 
are. 

It is probably true that babies fed on boiled milk are more 
likely to develop scurvy than those fed on raw milk. In most 
of the investigations of scurvy that have been undertaken it 
has been found that more babies developing it have been fed 
on boiled milk than on any other one sort of diet. On the other 
hand, in Germany and France, where boiled milk is used almost 
exclusively, there is apparently no more scurvy than there is 
here, where more raw milk is used. Boiled milk is certainly not 



174 PEACTICAL INFANT FEEDING 

the entire cause of scurvy, as babies may sometimes develop 
it when fed on raw cow's milk or even on the breast. Orange 
juice in sufficient quantities (1 ounce a day) is a practically 
sure prophylactic, and the dangers of scurvy in a baby who is 
being fed intelligently on a sufficient quantity of fresh boiled 
milk, with the addition of orange juice, are practically nil. 
The fact that some babies develop scurvy when fed on boiled 
milk without the addition of orange juice in sufficient quantity 
cannot be taken as an argument against boiled milk. I say 
"sufficient quantity" because I have seen a number of babies 
with scurvy who had been taking an insufficient quantity of 
orange juice — 1 teaspoonful a day or less. It is true that a cer- 
tain amount of the calcium salts present are precipitated in 
insoluble forms by boiling milk, and are thus probably made 
unavailable for the baby. But there is such a large excess of 
calcium salts present in cow's milk that it is probable there is 
enough left in available forms to supply the baby's needs. 
There are few exact investigations on record concerning this 
point, and it must remain more or less a matter of conjecture 
until more light is shed upon it. As regards rickets, it has 
been said that lack of available calcium and destruction of 
vitamins in boiled milk cause babies fed on it to develop rickets 
more often than those fed on raw milk. There is no positive 
evidence to support this. We do not know that the calcium 
balance in babies fed on boiled milk is affected unfavorably, 
nor has it ever been positively shown that lack of vitamins 
is the cause of rickets. Inasmuch as there is no exact experi- 
mental evidence to support this idea, we must rely on general 
clinical observation, and from my own experience and from 
that of my colleagues at the Children's Hospital I should say 
that babies fed on boiled milk were no more likely to develop 
rickets than those fed on raw milk. 

It is true that in some cases boiled milk is somewhat con- 
stipating, but this constitutes no real disadvantage, as a slight 
amount of constipation does no harm and can be easily con- 
trolled. Boiled milk is just as nutritious as raw milk, as it has 



175 

been shown a number of times that the absorption of the food 
elements is not deleteriously affected by boiling. It is true 
that the ferments of milk are destroyed by boihng, but inas- 
much as it is not known what place the ferments hold in nutri- 
tion or whether they are of any value, their destruction cannot 
count as an important argmnent against boiled milk. 

We see, then, that there are very few tangible arguments 
against boiled milk; we really know practically nothing about 
the relationship of boiled milk to rickets, and can protect our 
babies easily against scurvy. These possible disadvantages 
of boiled milk certainly cannot outweigh that most important 
of all advantages — a milk free from harmful bacteria. 

Raw Milk versus Boiled or Pasteurized Milk. — There are 
many differences of opinion as to whether milk for infant feed- 
ing should be used raw, boiled, or pasteurized. My own per- 
sonal opinion is as follows: No milk should he fed raw to infants 
or children under three years of age unless it is certified milk or of 
equal grade. During hot, muggy weather even certified milk should 
not he used raw, and in the South all milk for hahies should he either 
hoiled or pasteurized at all times, whether it is certified or not. Inas- 
much as the amount of certified milk availahle comprises only ahout 
1 per cent, of the total milk supply, most hahies will have their 
milk cooked. 

Boiled versus Pasteurized Milk. — ^As far as the general 
milk supply is concerned, pasteurization is satisfactory. As 
regards infant feeding and the heating of milk in the home, 
boihng is so much more simple than pasteurization that most 
pediatrists have discarded the latter method, and although 
certain disadvantages have been supposed to go with boiled 
milk, these do not equal its advantages. In using market 
milk which has already been pasteurized in the winter there 
is no need to recook it in the home unless to make a softer casein 
curd; in the smnmer it should be reboiled. 

Milk at Summer Resorts. — Most mothers who take their 
children away for the summer to the seashore or country worry 
a great deal about the milk supply, and often have their pet 



176 PRACTICAL INFANT FEEDING 

milk sent each day from the city in special ice-boxes at con- 
siderable expense and trouble. There is no need of this. At 
almost any summer resort a farmer can be found who has reason- 
ably good milk; this can be boiled as soon as it is delivered, 
and is Kkely to be a good deal better than any milk from the 
city, as it is very much fresher. 

THE ESSENTIAL DIFFERENCES BETWEEN COW'S MILK AND 

HUMAN MILK 

It is necessary, in order to understand the nutritional proc- 
esses of babies fed on cow's milk, to have a clear idea of the 
essential points in which it differs chemically from human milk. 

Fat. — ^The fats of the two milks differ considerably in their 
chemical nature. The fat of human milk contains only about 
2 per cent, of the lower irritating volatile fatty acids, that of 
cow's milk contains anywhere from 6 to 27 per cent., accord- 
ing to different observers. It is possible that this high content 
in irritating acids, especially butyric and caproic, may have a 
good deal to do with the difficulty that some infants have in 
digesting cow's fat. 

Of the more volatile acids, oleic makes up at least 50 per 
cent, of the total fatty acid content of human milk fat, whereas 
it makes up only 35 per cent, of the total content of cow's fat. 
Cow's milk fat contains a good deal more palmitin than does 
that of human milk. The calcium soaps of oleic acid are much 
more easily absorbed than those of palmitic acid. This may be 
another reason why the fat of human milk is tolerated better 
than that of cow's milk. The fat globules of human milk are 
probably in a much finer emulsion than in cow's milk. "When 
the number of droplets are counted in a counting chamber 
there are always more in human than in cow's milk. The fat 
globules in human milk measure between 0.001 and 0.02 mm., 
while those in cow's milk measure 0.0016 to 0.01 mm. Since 
the measurements given above show that the fat droplets in 
himian milk may be of greater diameter than those in cow's 
milk, it seems inconsistent that there should be a larger number 



cow's MILK 177 

in the former than in the latter. The explanation must be that 
the majority of fat droplets in human milk are small and measure 
about 0.001 mm., while the majority of those in cow's milk 
must be closer to the upper limit and measure nearly 0.01 mm."^ 
The larger the number of fat globules, the greater the surface 
area for the fat-splitting ferments to work on, and, therefore, 
more complete digestion of the fat. This may be another reason 
why the fat of human milk is better as an infant food than 
that of cow's milk. 

Protein and Salts. — Cow's milk contains over twice as much 
protein and over three times as much ash as does human milk. 
This is on account of the more rapid growth of the calf, which 
needs a large amount of protein and of salts in order to supply 
material for the rapid growth of bone and muscle tissue. 

It is interesting to note that in most mammalia the ash 
and protein content of the milk of each species is in inverse 
proportion to the length of time needed for the young to double 
its birth weight.^ 

Period in which 
Species. weight of newborn 100 grams of milk contain 

is doubled (days). Protein, gm. Salt, gm. 

Man.... 180 1.25 0.20 

Horse 60 2.0 0.40 

Cow 47 3.5 0.70 

Goat 22 3.7 0.80 

Sheep 15 4.9 0.80 

Pig 14 5.2 0.80 

Cat 9.5 7.0 1.0 

Dog 9 7.4 1.3 

Rabbit 6 10.4 2.50 

Most of the protein in cow's milk is casein, in the proportion 
of about 6 parts of casein to 1 of lactalbumin. In human milk, 
according to most authors, the casein and lactalbumin are 
about equally divided. 

Cow casein is probably not the same substance chemically 

that human casein is. Cow casein contains 0.87 per cent, of 

^ Morse and Talbot, "Infant Feeding and Diseases of Nutrition," 1915. 
2 Table by Proscher and Abderhalden (quoted by Hawk, Physiological 
Chemistry). 



178 PRACTICAL INFANT FEEDING 

phosphorus, human casein only 0.25 per cent. Cow casein 
coagulates in the stomach in tough, leathery masses, human 
casein in fine flakes. 

The salt content of cow's milk is greatly in excess of that of 
human milk, and although we know as yet relatively little re- 
garding the metabolism of the salts and their effect in produc- 
ing disturbances of digestion or of nutrition, it is undoubtedly 
true that the large amount of inorganic material, particularly 
salts of calciimi, of sodium, and of phosphorus, and the forms 
in which they are found, have a great deal to do with some of 
the disturbances in babies fed on cow's milk. Cow's milk is, 
however, much poorer in iron than human milk, and this, too, 
has an important bearing on practical infant feeding, because 
babies fed too long on milk, without other iron-containing food 
are likely to become anemic and flabby. 

Salt Content of Human and Cow's Milk (Langstein and Meyer) 

1000 grams of ash contains: 

Human. Cow. 

K2O, 0.69 gm 1.885 gm. 

NaaO, 0.16 " 0.465 " 

CaO, 0.42 " 1.72 " 

MgO, 0.068 " 0.205 " 

FeaOs, 0. 001-0. 004 gm . 0004-0 . 0007 gm. 

CI, 0. 294 gm 0. 820 gm. 

SO3, 0.143 " " 

P2O5, 0. 249-. 0418 gm. 2.065-2.437 gm. 

1.988 gm 7.553 gm. 

The high salt content is important in relation to the fat 
digestion also, as it probably favors the formation of insoluble 
calcium soaps, which are difficult of absorption. 

To sum up: 

1. There are important physical and chemical differences 
between the fats in the two milks, which indicate that the fat 
of cow's milk would be digested and absorbed with more diffi- 
culty than that of human milk. 

2. The total protein is considerably higher in cow's milk. 
This is due to the large amount of casein in cow's milk. It is 



cow's MILK 179 

a different substance chemically from that in human milk, and 
is probably digested with more difficulty. 

3. The salt content of cow's milk is very high in comparison 
with that of human milk. This would seem to be of especial 
importance as regards the calcium salts, the large excess of 
which probably has a good deal to do with disturbances of fat 
metaboHsm. 

With these differences in mind it is not hard to see why the 
metabolic processes of breast-fed and artificially fed babies 
are very different, and why there is so much possibility for a 
totally different category of digestive and nutritional disturb- 
ances to develop in the artificially fed than in the breast-fed 
infant. 



CHAPTER VII 
THE MODIFICATION OF MILK^ 

By the "modification" of milk is meant changing the compo- 
sition of the original cow's milk in order to make it suitable 
for the digestion of the particular infant that is being fed. It 
is possible to successfully feed some babies on undiluted cow's 
milk, but these babies represent a very small minority, and 
for practical purposes it may be said that it is always neces- 
sary to modify cow's milk before it is fed to young babies. In 
the past fifty years there have been proposed numerous methods 
of modif5dng milk; some authorities have recommended simple 
dilutions of whole milk, while some have felt that babies generally 
do better if more fat is given, and have, therefore, added cream 
to the modification or have used dilutions of cream in order to 
obtain the higher fat content. It is often possible to feed the 
normal baby on a wide variety of foods, as he has considerable 
power of adapting himself within certain limits to changes in 
the composition of his diet. Thus it may be said that no one 
method of milk modification is the only one that should be 
used, and others need not be necessarily erroneous. Any method 
of milk modification is correct for any particular baby if the 
mixture contains the proper amounts and proportions of the 
various food elements for him to grow and develop normally. 
It is desirable, however, to proceed in a rational manner, to 
change the original cow's milk by design and not haphazard, 
and to have at one's command methods of milk modification 
which will allow of varying at will the individual constituents 
of the milk — fat, sugar, protein, and salts — to meet the needs 
of various babies with different digestive powers. It is also 
desirable in any system of milk modification to have a way of 

* Part of this chapter was published in the Journal of the American 
Medical Association, March 5, 1921. 
i8o 



THE MODIFICATION OF MILK l8l 

expressing what has been done in the exact language of figures 
in order to make it clear to ourselves, in order to make it intel- 
ligible to others, and in order to make our procedures avail- 
able for purposes of record. There is, therefore, involved in 
any method of milk modification a certain amount of calcula- 
tion. Much of the confusion in the minds of practitioners and 
students that there is in regard to infant feeding has arisen on 
account of the numerous ways of calculation and methods of 
modification that have been recommended by different authori- 
ties. The important thing to remember is that the particular 
method of modification which has been used is not the significant 
fact, but that the content of the resulting mixture as regards 
the various food elements is the point that must be continually 
borne in mind, and that many times the identical result may be 
obtained by two quite different methods of modification. An 
intelligent practitioner should know his food elements, should 
have clearly fixed in his mind approximately how much of each 
one of these elements he desires to feed to the baby, then he may 
proceed to concoct this combination by means of any method 
of modification with which he may be familiar. Some men 
get into the habit of using one particular method, others may 
use methods which are radically different, but may secure 
equally good results. Any one who is feeding babies should 
have at his command several methods, and should use the one 
which is most adaptable to the particular case with which he 
happens to be dealing. No matter what methods he uses, he 
must continually keep the food elements in mind, and must 
have some method of expressing to himself and to others the 
amounts of these that he is using. 

There are at present three methods of milk modification in 
general use: 

1. The method of whole milk dilution. 

2. The method of top milk (cream) dilution. 

3. The method of gravity cream and skimmed milk mixtures. 
Whole Milk Dilutions. — This is the simplest method of 

milk modification. It was the first one used in the early days 



l82 PRACTICAL INFANT FEEDING 

before the development of modern infant feeding, and in the 
last ten years has had a revival of popularity. Its chief advantage 
is its simplicity; any mother, no matter how ignorant she may 
be, can be easily taught to mix together milk, water, and sugar. 
It is also easy for the doctor; and most men who are in the 
habit of using whole milk dilutions pay but Uttle attention to 
the percentages of the food elements in the mixture; they think 
rather in terms of ounces of milk and of sugar. It is possible 
in many cases to feed babies successfully by this method, but 
it has its limitations, in that it is not at all elastic, and often 
the ratios which one would like to have between the fat and 
protein in the mixtures cannot be obtained, owing to the fact 
that if the milk is diluted one-third or one-half, as the case may 
be, the fat and the protein will each be diluted in the same 
proportion. It is very successful with many well babies, but 
as soon as the baby fails to gain, or begins to do poorly in any 
way, its disadvantages become apparent, as all that can be done 
is to either increase or diminish the total concentration of milk 
or of sugar in the mixture. In whole milk dilutions, therefore, 
the ratio between the fat and the protein will always be the 
same, and it is impossible to feed high fats by the use of this 
method, as the fat content of the milk is so much reduced by 
dilution. It does not apply so well to very young babies as do 
the other methods of milk modification, as the usual dilution 
is so great that the fat percentage of the resulting mixture is 
much lower than the baby might be able to take with advantage. 
In normal babies after the eighth or ninth month it is, however, 
the method of choice, as the dilution for these older babies is 
so sUght that the fat percentage is not much reduced. My 
own feeling is that young babies as a rule do better on higher 
fat and lower protein percentages than can be obtained by this 
method of feeding. There is no question, however, that many 
babies may be successfully fed in this way. The chief objection to 
it is that it is not comprehensive nor elastic enough to furnish us 
with certain combinations of the food elements that we may need, 
and every practitioner should have in his armamentarium other 



THE MODIFICATION OF MILK 183 

methods in addition to this one. Even if whole milk dilutions 
are used, and no matter how much infant feeding is simpHfied 
by their use, it is always well to keep track of the approximate 
percentage of each food element in the mixture. It is not pos- 
sible nor desirable to get away from a certain amount of calcu- 
lation, and a knowledge of the percentage composition of the 
food acts as a check upon what is being done. No matter what 
method of milk modification one adopts, in order to have any 
idea whatsoever about the possibiHties of his mixture he must 
have at least approximate knowledge of its elementary compo- 
nents (fat, sugar, protein) . The easiest way to have this knowl- 
edge is to think and speak in terms of percentages. 

Whole milk dilutions may be used in either one of two ways; 
the usual procedure being the first: 

1. The desired number of ounces of milk and water plus 
the desired number of tablespoonfuls of sugar are prescribed; 
then the percentage composition of the mixture is calculated. 
In using whole milk dilutions one does not usually pick out 
in advance the percentage composition of the formula, as in 
many cases he will have picked out a formula which cannot 
be obtained by these methods. After a certain amount of 
experience in using this method, one knows without calculation 
about what the percentage composition of any given dilution 
of whole milk is, and he expresses his formula in terms of ounces 
of milk and water and tablespoonfuls of sugar rather than in 
terms of percentages. In order to proceed rationally, in order 
to have a clear conception of what he is doing, and especially 
in order to keep his food elements in mind, he must, however, 
have an idea of the percentage strength of his mixture. Every 
competent jeeder of infants has this knowledge, whether he expresses 
it on paper or not. 

Let us suppose that the baby is being fed on whole milk, 
36 ounces; water, 12 ounces, and lactose (milk-sugar), 4 level 
tablespoonfuls. Then, as whole milk contains fat, 4 per cent.; 
sugar, 4.5 per cent., and protein, 3.2 per cent., we are giving 
if or f whole milk, which equals f of 4=3 per cent, of fat 



l84 PRACTICAL INFANT FEEDING 

in the mixture; | of 4.5=3.3 per cent, of sugar in the mixture, 
and f of 3.2 = 2.4 per cent, of protein in the mixture. 

A level tablespoonful of lactose added to a 48-ounce mixture 
raises the sugar percentage 0.8 per cent. (Table I). Therefore, 
using 4 level tablespoonfuls of dry lactose, we have added 3.2 
per cent, of sugar to the mixture, which, plus the sugar that has 
already been put in with the milk (3.3 per cent.), gives 5.5 per 
cent, total sugar, and the baby is getting: fat, 3 per cent.; 
sugar, 5.5 per cent., and protein, 2.4 per cent. 

The same method is used in figuring any whole milk dilution.^ 

Level tablespoonfuls of sugar are best calculated by the 
use of the sugar table, and ordinarily I believe it is best to use 
level tablespoonfuls instead of rounded, as more accuracy is 
obtained in this way. If rounded tablespoonfuls were used the 
calculation would be a little different. Suppose we had used 
in the foregoing formula 3 rounded tablespoonfuls of lactose. 
A rounded tablespoonful of lactose weighs | ounce; therefore 
we have added IJ ounces of lactose. To transfer this to per- 
centages, ^^ X 100 = 3.1 per cent, sugar added. 

Table I will be found convenient to remember; it is, I think, 
the easiest way to calculate sugar. 

Sucrose (cane-sugar) is somewhat heavier than lactose. 
Dextrimaltose is somewhat lighter (Table II). 

It is not necessary, however, to make special calculations 
for sucrose or for dextrimaltose; it is usually accurate enough 
to calculate as if for lactose, and then, if using sucrose, to use 
a little less than the calculation calls for; if using dextrimaltose, 
a little more. 

2. The second way of using whole milk dilutions is with 
the aid of a table, and is not quite so practical as the first method. 
In any whole milk and water dilution, if five-sixteenths of the 
mixture is milk, that is, 5 ounces of milk in a 16-ounce mixture, 

* In using this method there is no necessity of being too accurate ; for 
example, supposing we were using 10 ounces of milk and 22 ounces of water 
in a mixture, it would be perfectly correct to call this one-third milk, or fat, 
1.3; sugar, 1.5; protein, 1.1. 



THE MODIFICATION OF MILK 185 

and the rest water, the percentages are: fat, 1.25; sugar, 1.40; 

protein, 1. Similarly, if more milk is added, the percentages 

are as given in Table III. 

TABLE I 

Calculation of Sugar 

One level tablespoonful of lactose raises the sugar percent- 

age^- 

2.40 in a 16-ounce mixture 
2 . 00 in a 20-ounce mixture 
1 . 60 in a 24-ounce mixture 
1 . 20 in a 32-ounce mixture 
1 . 00 in a 40-ounce mixture 
0. 80 in a 48-ounce mixture 

TABLE II 
Comparative Weights of Sucrose, Lactose, and Dextrimaltose 

Sucrose, Lactose, Dextrimaltose, 

gm. gm. gm. 

1 level tablespoonful ... 15 10 9 

1 rounded tablespoonful. ... 25 16 14 

Measures 
3 level teaspoonfuls = 1 level tablespoonful 
2 level tablespoonfuls = 1 large kitchen spoonful 

TABLE III 

Percentages of Fat, Sugar, and Protein, According to Proportion 
OF Milk in Mixture 

Milk. Fat. Sugar. Protein. 

A-... 1.50 1.70 1.20 

■^ 1.75 2.00 1.40 

•^ 2.00 2.25 1.60 

A 2.21 2.50 1.80 

if 2.50 2.80 2.00 

^ 2.75 3.00 2.20 



T6 
16 



^ 3.00 3.30 2.40 



The amount of sugar necessary to add can be determined 
by referring to the sugar table (Table I). The table of whole 
milk dilutions is calculated on the basis of sixteenths. Of 

* These figures are not absolutely accurate, but are near enough for prac- 
tical purposes, and are adopted for the sake of convenience. 



l86 PRACTICAL INFANT FEEDING 



course, if one is dealing with a 32-ounce or a 48-ounce mixture, 
the fraction A or A, etc., is multiplied through by 2 or 3, as 
the case may be; that is, A is the same as M or if. Propor- 
tionate calculations can be made for 24-ounce or 40-ounce 
formulas; that is, in a 24-ounce mixture the amount of milk 
required to give the same percentages would be IJ times what 
it would be for a 16-ounce mixture, or in a 40-ounce mixture it 
would be IJ times what it would be for a 32-oimce mixture. 
Thus we can accurately figure from this table 16-, 24-, 32-, 
40-, and 48-ounce mixtures, which are the most common ones 
used. 

Top Milk (Cream) Dilutions. — The top portions of a quart 
of milk, after it has been allowed to stand about six hours, con- 
tain varjdng amounts of fat, as in Table IV. 

TABLE IV 
Amount of Fat in Top Milk^ 

Per cent. fat. 

Top 2 ounces mixed contain 24. 

Top 3 ounces mixed contain 22.5 

Top 4 ounces mixed contain 21.4 

Top 5 ounces mixed contain 19. 2 

Top 6 ounces mixed contain 16. 8 

Top 7 ounces mixed contain 15. 

Top 8 ounces mixed contain 13 . 3 

Top 9 ounces mixed contain 11.5 

Top 10 ounces mixed contain 10. 5 

Top 12 ounces mixed contain 9.0 

Top 14 ounces mixed contain 7.8 

Top 16 ounces mixed contain 7.0 

Top 18 ounces mixed contain 6.3 

Top 20 ounces mixed contain 5.8 

Top 22 ounces mixed contain 5.4 

Top 24 ounces mixed contain 5.0 

Top 26 ounces mixed contain 4.7 

Top 28 ounces mixed contain 4.5 

Top 30 ounces mixed contain 4.3 

It is possible by different dilutions of these creams of vary- 
ing fat percentage to secure mixtures containing more fat than 
is possible with the use of whole milk dilutions. High fats and 
* From Morse and Talbot's Infant Feeding. 



THE MODIFICATION OF MILK 187 

rather low proteins are obtained by the use of this method of 
modification, whereas by the use of whole milk dilutions low 
fats and relatively high proteins are obtained, as we have seen. 
As may be seen from the table, there are a good many different 
strengths of cream which may be used; practically it will be 
found best to confine oneself to the use of the top 10 ounces, 
top 16 ounces, and top 24 ounces, containing 10, 7, and 5 per 
cent, of fat respectively. The amounts of sugar and of protein 
contained in these three different creams vary a Kttle, as shown 
by Table V; but the variations are so shght that they may be 
disregarded, and for practical purposes the sugar and protein 
content of the various creams may be considered to be 4.50 
and 3.20 per cent, respectively. 

In using these three creams the possible combinations which 
would be of practical value in infant feeding are as given in 
Table VI. Sugar may, of course, be added up to any desired 
percentage, using the same sugar table as for whole milk dilu- 
tions. 

TABLE V 

Composition of 10, 7, and 5 Per Cent. Creams^ 

. Percentages . 

Fat. Sugar. Protein. 

10 per cent, cream 10.00 4.40 3.25 

7 per cent, cream 7.00 4.45 3.40 

5 per cent, cream 5.00 4.50 3.50 

TABLE VI 

Formulae From 10, 7, and 5 Per Cent. Creams of Practical Value 

Combination. , Percentages . 

10 per cent. : Fat. Sugar. Protein. 

Cream, 1 part ; water, 2 parts 3.3 1.5 1.1 

Cream, 1 part; water, 3 parts 2.5 1.1 0.80 

7 per cent. : 

Cream, 1 part; water, 1 part 3 . 50 2 . 25 1 . 60 

Cream, 1 part; water, 2 parts 2 . 50 1 . 50 1 . 10 

Cream, 1 part; water, 3 parts 1 . 80 1 . 10 0. 80 

5 per cent.: 

Cream, 2 parts; water, 1 part 3.2 3. 00 2.2 

Cream, 1 part; water, 1 part 2 . 50 2 . 25 1 . 60 

Cream, 1 part; water, 2 parts 1 . 70 1 . 50 1 . 10 

1 From Morse and Talbot's Infant Feeding. 



l88 PRACTICAL INFANT FEEDING 

This method of milk modification is employed considerably, 
and when used with intelligence carries with it no objections. 
It is not at all imcommon, however, to see mixtures containing 
5 or 6 per cent, of fat obtained by this method, which is, of 
course, quite unsuitable for any baby. If cream dilutions are 
used, the fat content of the original cream and of the resulting 
mixture must be borne carefully in mind. Many men forget 
this. It is possible, of course, in using this method to get in- 
numerable formulas by various dilutions of 6, 8, and 12 per cent, 
creams, or by dilutions of the bottom milk after certain amounts 
of the cream have been removed; but the introduction of so 
many different strengths of cream and of milk makes such a 
complicated array of figures which are so difficult to remember 
that it is best for practical purposes, if using this method, to 
confine oneself to dilutions of 10, 7, and 5 per cent, creams, 
as given above. The use of even these three strengths of cream 
introduces an unnecessary complication, as any mixture that 
can be obtained by these methods can likewise be obtained by 
the gravity cream and skimmed milk method by using only one 
standard strength of cream in combination with skimmed milk. 

Gravity Cream and Skimmed Milk Mixtures. — The method 
of gravity cream and skimmed milk mixtures is the method of 
milk modification that is the most adaptable to the needs of 
various babies. In one respect it is more complicated than the 
other methods, as instead of using simply dilutions of milk or 
of cream, when we have but one diluted factor to consider, 
we have here two diluted factors. The purpose of this method 
is to furnish a means of obtaining practically any combination 
of the food elements that we desire. Most of the protein is 
furnished by the skimmed milk; then enough cream of a known 
fat content (16 per cent.) is added to supply the required fat 
percentage. It is inevitable in any such method as this that 
there should be a certain amount of calculation; we could not 
speak simply in terms of so much cream, skimmed milk, water, 
and sugar, and have any idea whatever of what we were giving 
to the baby. We must speak in terms of percentages always 
in using this method. 



THE MODIFICATION OF MILK 189 

My own feeling is that this is the best method of milk modi- 
fication for general use. It does not apply to very ignorant 
patients who have not the inteUigence or the desire to go through 
the procedure involved; for these whole milk dilutions must be 
used. Most mothers or nurses will be able to handle gravity 
cream and skimmed milk dilutions without trouble, however, 
and the amoimt of calculation involved for the practitioner 
is not at all difficult or complicated when it has been once 
mastered. It is a most practical and intelligent way of feeding, 
and enables the practitioner to change the amounts of protein 
and of fat in his mixtures much more easily than by any other 
method. It tends to do away with empiricism, and tends to 
make those using it think more accurately in terms of the food 
elements than they would otherwise. Its disadvantage is that 
there is more calculation involved in it than in the other two 
methods of milk modification. If it is worth while, if it offers 
advantages, and I believe it does, the small amount of extra 
trouble involved should not count against it. 

Let us consider for a moment what we mean by gravity 
cream and skimmed milk. After a quart of milk in the ordinary 
milk jar has stood about six hours the cream comes to the top, 
and is separated from the milk by a fairly definite line known 
as the cream line. All this cream is known as gravity cream. 
This will usually amoimt to about 6 ounces. All the cream down 
to the cream line is then gravity cream, and contains: fat, 16; 
sugar, 4.5, and protein, 3.2 per cent. What is left behind is the 
"skimmed milk," which contains: fat, 0; sugar, 4.5, and protein, 
3.2 per cent. These figures are not strictly accurate, but the 
errors in one counterbalance those in the other. "Skimmed 
milk" actually contains a little fat, but for practical purposes 
this may be disregarded. The advantages of using "gravity" 
cream instead of creams obtained in other ways is that it does 
away with confusion, and we have simply to remember that the 
cream we are dealing with always contains 16 per cent, of fat 
instead of trying to remember the fat content of several different 
layers of cream, as is done by the "top milk" method. The 



igo PRACTICAL INFANT FEEDING 

best method of separating the gravity cream from the skimmed 
milk is to dip it off with a Httle dipper devised by Dr. Henry 
Chapin, of New York, and called, after him, the ''Chapin dip- 
per.'' This can be obtained at any large drug store. Pouring 
can be used if no dipper is obtainable, but it is not quite so 
accurate. An important practical point to remember is to tell 
the mother to remove all the cream on the quart, and to explain 
to her carefully what gravity cream is. Otherwise she is very 
likely, supposing the formula calls for 3 or 4 ounces of cream, 
to take off simply the top 3 or 4 ounces, and use this, in which 
case she would be using a 20 or 22 per cent, cream, and would 
be putting more fat in the mixture than was prescribed. All 
the cream down to the cream Hne should be removed, put into 
a bowl, and mixed; then the required number of ounces is taken 
from this. 

Calculation of Formulce. — There are two ways of calculat- 
ing gravity cream and skimmed milk mixtures, which may be 
called the "long" method and the "short" method. The long 
method employs no short cuts, calculates each ingredient step 
by step, and is a rather laborious procedure. It is not necessary 
to use it in actual practice, but it is desirable to know, as he who 
understands this method of calculation will understand the 
principles of calculating the percentages of any formula, no 
matter what its ingredients are, without the use of any tables 
or equations. Inasmuch as the "short method" is the best 
to use in actual practice, however, and in order to avoid con- 
fusion, I have put the long method in an Appendix at the end 
of the chapter. 

Short Method. — The easiest way of calculating gravity cream 
and skimmed milk mixtures is by the use of a table of factors, 
which can be carried in the pocket or notebook on a little card, 
and which is easily memorized after it has been used a few times. 
By its use all the necessary calculation can be done in the head. 
The question of calculation is what has deterred many men 
from using the gravity cream and skimmed milk method, and 
it is true that the i<Hig way of calculating is rather laborious. 



THE MODIFICATION OF MILK IQI 

Nor have the various algebraic equations which have been pro- 
posed from time to time helped the situation; they have made 
it more complicated. The method about to he described is really 
practical and simple, and the calculation involved is so easy that 
no one need he daunted by it, no matter how hazy he may be with 
regard to mathematics. By its use we are confined to 16-, 20-, 
24-, 32-, 40-, and 48-ounce mixtures; but as these are the mix- 
tures ordinarily used, this is not a disadvantage. The basis 
of the method is that in these mixtures certain constant simple 
ratios exist between the fat percentage desired and the number 
of ounces of gravity cream required to get it; also, definite 
ratios exist between the protein percentage desired and the 
number of ounces of cream plus skimmed milk required to get it. 

Principles of Calculation. — ^Amount of Cream. — In a 16- 
ounce mixture the number of ounces of gravity cream required 
is always the same as the fat percentage desired. In a 32-ounce 
mixture the number of ounces of gravity cream required is 
always twice the fat percentage desired; in a 48-ounce mixture, 
three times. There are similar factors for the other mixtures 
(20-, 24-, and 40-oimce mixtures — Table VII). This does away 
with all paper calculations, as the whole thing is so simple that 
it can be done in the head in a moment. 

Amount of Skimmed Milk. — In a i6-ounce mixture the 
number of ounces of skimmed milk, plus cream required, is 
always 5 times the percentage of protein desired; in a 32-ounce 
mixture, 10 times; in a 48-ounce mixture, 15 times. Similar 
factors exist for the other mixtures (20-ounce, 24-ounce, etc.). 
The number of ounces of skimmed milk necessary is easily ob- 
tained by subtracting the number of ounces of cream obtained 
in the first calculation from the number of ounces of cream plus 
skimmed milk obtained in the second calculation. 

Amount of Sugar to Add. — Some sugar is, of course, put in 
with the cream and skimmed milk, as both of these contain 
sugar. In order to know how much more sugar to add in the 
form of dry sugar to bring the total up to the desired percentage 
it is necessary first to know what percentage the cream and 



192 PRACTICAL INFANT FEEDING 

skimmed milk furnished. The percentage of sugar furnished 
by the cream and skimmed milk is always IJ times the per- 
centage of protein desired. The extra sugar to be added is 
figured from the sugar table, showing how much the percentage 
of sugar is increased in any mixture by adding a level table- 
spoonful of sugar. 

TABLE VII 
Factors 

Fat factor.! Protein factor.* 

16-ounce mixture 1 . 00 5. 00 

20-ounce mixture 1 . 25 6. 25 

24-ounce mixture 1 . 50 7.5 

32-ounce mixture 2.0 10.0 

40-ounce mixture 2. 50 12. 5 

48-ounce mixture 3.0 15.0 

Sugar Table 
One level tablespoonful of lactose raises the sugar percentage: 
2.40 per cent, in a 16-ounce mixture 
2 . 00 per cent, in a 20-ounce mixture 
1 . 60 per cent, in a 24-ounce mixture 
1 . 20 per cent, in a 32-ounce mixture 
1 . 00 per cent, in a 40-ounce mixture 
0. 80 per cent, in a 48-ounce mixture 

Example 
Suppose we wish a 32-ounce mixture containing: fat, 2.5; sugar, 6, and 
protein, 1 per cent. 
To determine: 

1. Gravity cream: 2.5 X 2 (fat factor for 32 oz.) = 5 oz. gravity 

cream. 

2. Skimmed milk: 1.00 X 10 (protein factor for 32 oz.) = 10 oz. 

skimmed milk plus cream. Minus 5 oz. cream = 5 oz. 
skimmed milk. 

3. Sugar: 

(a) Sugar furnished by skimmed milk and cream: 1.00 (pro- 

tein percentage desired) X H = 1.50 per cent, sugar. 

(b) Sugar to add as dry lactose: 6.00 — 1.50 = 4.50 per 

cent, more to be added. One level tablespoonful of 
dry milk-sugar added to a 32-oz. mixture raises the 
sugar percentage 1.2 per cent. Therefore add 4 
level tablespoonf uls of milk-sugar. 

1 Multiply by percentage of fat desired. This gives ounces of gravity 
cream to use. 

2 Multiply by percentage of protein desired. This gives ounces of gravity 
cream plus skimmed milk to use. 



THE MODIFICATION OF MILK 1 93 

This is an accurate and exceedingly simple method once its 
details are understood, and by its use the gravity cream and 
skimmed milk method of modification should be robbed of its 
difficulties and be made practical for general use. If the reader 
will take the trouble to study it, he will see that this is true. 

It seems to me that the best thing for the average practi- 
tioner to do is to learn the whole milk and the gravity cream and 
skimmed milk methods, discarding the method of top milk dilu- 
tions. He will then have at his command a wide range of 
formulae, and if he desires to feed more fat to his babies than 
can be obtained by the whole milk method (which is undoubtedly 
serviceable in many cases), he can turn to gravity cream and 
skimmed milk mixtures. Any method of calculation seems 
complex and difficult to understand at first glance; at least it 
does to me in any text-book of infant feeding I may happen 
to pick up. Let me insist that no man can learn a method o] 
calculating milk formulas by simply reading it over once or twice; 
he must take pencil and paper, sit down and figure a few sample 
formulcB. Then he will have no trouble. It is worth while 
to be able to feed with accuracy. The old days of haphazard 
feeding have gone by; but there are altogether too many practi- 
tioners even now who do not know what they are feeding their 
babies; to them cream is simply "cream,'' irrespective of its 
fat content; many of them have not even a knowledge of the 
composition of whole milk. The obtaining of approximate 
accuracy in infant feeding is so easy that it seems a pity it 
should not be universally adhered to. I say ''approximate 
accuracy," for, of course, it is not possible or necessary to 
secure absolute accuracy in any milk modification. The in- 
gredients vary too much; and any chain is only as strong as 
its weakest link. Relative accuracy is what is desired, and in 
calculating formulae it is not necessary to pay much attention 
to insignificant fractions. The ability to express in numerical 
terms the approximate amount of each individual food element 
in the baby^s milk mixture seems to me a necessary fundamental 
of scientific infant feeding. 
13 



194 PRACTICAL INFANT FEEDING 

Expression in percentages has been usually employed. 
Expression in grams or in drams would be equally as good if 
one were accustomed to think in that way. The "percentage 
method," so called, is really not a method of feeding; it is a 
method of expression merely, and it does not demand that those 
who follow it should feed high or low fats, sugars, or proteins; 
it merely requires that cognizance should be taken of the amounts 
of these elements that are to be fed. The expression of these 
amounts in terms of percentages is usually the most convenient 
notation to adopt. 

Calories. — It is often of advantage to know approximately 
how many calories are contained in the formula. The caloric 
value of the food is determined not in advance, but after the 
modification has been made up, merely as a check. This may be 
calculated in a number of different ways, according to what 
method of milk modification one is using. 

I. The sum of twice the fat percentage given in the food plus 
the carbohydrate percentage (sugar or starch) plus the protein 
percentage, multiphed by IJ times the twenty-four-hour amount 
of food in ounces gives the total calories for the day. This 
may be represented by the following equation: 

(2F + S + P) I5 Qi = total calories per twenty-four hours. 
Example: 

32 oz. of a formula containing 

Fat. Sugar. Protein. 

3.00 7.00 2.00 are being used. 

2F = 6.00 
S = 7.00 

P = 2.00 \\ (daily quantity in ounces) = 40 
15.00 X 40 = 600 calories per day. 

II. In using whole milk dilutions: 

1 ounce of whole milk = 20 calories. 
1 level tablespoonful of milk-sugar = 40 calories. 
1 rounded tablespoonful of milk-sugar = 60 calories. 
1 ounce of milk-sugar = 120 calories. 

* Q represents the total number of ounces of modification taken in twenty- 
four hours. 



THE MODIFICATION OF MILK I95 

The Calculation oj Whey Mixtures. — Whey mixtures con- 
sist of whey as a basis, to which enough cream and sugar have 
been added to obtain the desired fat and sugar percentages, 
the purpose being to obtain a mixture relatively high in whey 
protein and low in casein. The smaller the amount of cream 
added, the lower will be the casein percentage. Therefore, 
if it is desired to obtain whey mixture with a very low casein 
content, which will still contain a considerable amount of fat, 
24 per cent, cream (the top 2 ounces from the quart) may be 
used instead of the ordinary 16 per cent, (gravity) cream. 
If 24 per cent, cream is used, calculate as if for 16 per cent, 
cream, and then use only two-thirds as much of it. For practical 
purposes it is not necessary to calculate the exact amounts 
of whey and casein in a whey mixture; we know that the per- 
centage of whey protein in whey is about 0.90 per cent., that 
this will be reduced slightly by the cream which is added, and 
that usually from 0.40 to 0.60 per cent, of casein is furnished 
by the cream which is added to obtain the usual 2 or 3 per cent, 
of fat. Any closer calculations make the prescribing of whey 
mixtures unnecessarily complicated without obtaining any 
additional information that is of practical value. The follow- 
ing is the usual procedure employed: Whey contains fat .00, 
sugar 4.50, whey protein 0.90. Suppose we wished a 32-ounce 
whey mixtiure containing 2 per cent, of fat and 6 per cent, of 
sugar. How much gravity cream is necessary to give 2 per cent, 
of fat in a 32-ounce mixture? By referring to the table of fat 
factors previously used in calculating ordinary modifications 
we see that in any 32-ounce mixture it is necessary to use twice 
the number of ounces of 16 per cent, cream as the fat percentage 
desired. In this case we want 2 per cent, of fat. Therefore 
use 4 ounces of cream. If 24 per cent, cream were used, two- 
thirds the amount, or about 2| ounces, would be used. The 
rest of the mixture is, of course, made up from whey (28 ounces). 
We desire 6 per cent, of sugar in the final mixture. How much 
sugar is already there? Inasmuch as whey and gravity cream 
are the only ingredients in the mixture, and each contains 



196 PRACTICAL INFANT FEEDING 

4.50 per cent, of sugar, the mixture contains this amount. 
Therefore we need to add 1.5 per cent, extra sugar or about 
Ij level tablespoons (see sugar table). 

If it is desired to calculate more acurately the amounts of 
whey protein and of casein in such a mixture, it can be done 
as follows: We had originally in our whey 0.90 per cent, of whey 
protein. But in our mixture we have somewhat reduced this 
by adding cream, which contains mostly casein, and a small 
amount of whey. We have a 32-ounce mixture, containing 28 
ounces of whey, therefore we have f| of 0.90 or 0.84 per cent, 
whey protein. How much casein did we add to the mixture in 
the gravity cream used? We added 4 ounces of gravity cream 
which contains 3.20 per cent, of protein to the 32-ounce mixture. 
Therefore A of 3.20 = 0.40 per cent, casein added. Then 

our final formula is whey ^. This calculation is not 

casem 0.40 

at all necessary, and is a cumbersome complication. 

The Calculation of Starch. — The ordinary barley-water de- 
coctions that are used as diluents contain about 1.50 per cent, 
starch.^ 

Therefore if we desired 0.75 per cent, starch in the mixture, 
the amount ordinarily used, one-half of the mixture would have 
to be barley-water. If we did not wish to dilute our formula 
so much, and still desired 0.75 per cent, starch, we could use a 
3 per cent, starch decoction, and use only one-half as much of it. 

Summary. — ^It is always desirable to know approximately 
the quantities of the various food elements that any milk modi- 
fication contains. These quantities could be expressed by any 
numerical notation, but the most convenient way of express- 
ing them is in terms of percentages. There are several methods 
of milk modification in use, and it is not of great importance 
which one is used provided the physician gives enough food in 
total quantity and the proper combination of individual food 
elements to suit the digestion of the baby that he is deaHng 
with, and that he knows approximately the quantity of each 
* Two rounded tablespoonf uls of barley flour to the quart of water. 



THE MODIFICATION OF MILK I97 

food element in the mixture, in order that he may vary these 
quantities at will, that he may be able to proceed in a rational 
manner, and that he may be able to express to others in the 
exact language of figures what he has done. The modification 
of milk is the mechanical part of infant feeding, it is not the 
calculation that is difficult — any inexperienced medical student 
can quickly learn milk modification and calculation; the part 
of infant feeding that is difficult, that requires judgment and 
experience, that often eludes many of us in spite of years of 
experience with many babies, is knowing when to feed what. 

APPENDIX 

The "Long" Method of Calculation. — Desirable to know 
in order to understand the principles involved in any modifi- 
cation, no matter what its ingredients are, but not necessary 
to use in actual practice: 

Per cent. 
Desired formula: Fat, 3.00 

Sugar, 7.00 
Protein, 2 . 00 
Total formula to equal 32 ounces. 

Per cent. 
Gravity cream contains: Fat, 16.00 
Sugar, 4.50 
Protein, 3.20 
Skimmed milk contains: Fat, 0.00 
Sugar, 4.50 
Protein, 3.20 

First Step. — The fat in the mixture is furnished entirely 
by the gravity cream. 

How much gravity cream do we need to furnish the desired 
3 per cent, of fat in a 32-ounce mixture? 

Inasmuch as gravity cream contains 16 per cent, of fat, 
and we want only 3 per cent, of fat in the mixture, 
A of 32 ounces = 6-ounce gravity cream. 

Second Step. — ^The protein in the mixture is furnished partly 
by the gravity cream and partly by the skimmed milk. 



1 98 PRACTICAL INFANT FEEDING 

What is the number of ounces of gravity cream plus skimmed 
milk required to furnish the desired percentage (2) of protein? 

Inasmuch as gravity cream and skimmed milk each contain 
the same amount of protein (3.20 per cent.), 
3J20 of 32 ounces = 20 ounces of skimmed milk plus gravity cream. 

The gravity cream needed is, we know by our previous 
calculation, 6 ounces. 

Therefore 20 — 6 = 14 ounces of skimmed milk. 

Third Step, — The sugar in the mixture is to be furnished 
partly by the gravity cream and skimmed milk used, partly 
by the addition of dry sugar. How much sugar does the cream 
and skimmed milk used contribute toward the desired 7 per 
cent.? 

If we had used 32 ounces of gravity cream in our 32-ounce 
mixture, we would have put in 4.50 per cent, of sugar, as each 
one of these ingredients contains 4.50 per cent, sugar. But the 
sum of the ounces of cream and skimmed milk used equals 
only 20 ounces. Therefore ft of 4.50 = 2.8 per cent, sugar was 
furnished by the gravity cream and skimmed milk used. 

Fourth Step. — How much dry sugar do we need? 

We have already put in 2.8 per cent, and we want 7 per cent. 

7.0 — 2.8 = 4.2 per cent, to be added as dry sugar. 

■jijo of 32 ounces = 1.3 ounces of dry sugar. 

A rounded tablespoon of milk-sugar = | ounce. 

Therefore add 2f rounded tablespoons of milk-sugar. 

Fifth Step. — How much water is to be added? 

We have used 20 ounces of skimmed milk and gravity cream. 
We want a 32-ounce mixture. 

Therefore 32 — 20 = 12 ounces of water. 

Our final formula is 

Gravity cream 6 ounces 

Skimmed milk 14 ounces 

Water 12 ounces 

Milk-sugar 2f rounded tablespoonfuls 

It is sometimes of advantage to figure backward; that is, 
supposing a mother tells us she has been using so many ounces 



THE MODIFICATION OF MILK I99 

each of gravity cream, skimmed milk, water, and milk-sugar, 
and we wish to know the percentages contained in the mixture. 
Taking the formula: 

Gravity cream 9 ounces 

Skimmed milk 21 ounces 

Water 18 ounces 

Milk-sugar 4 level tablespoonf uls 

First Step. — How much fat is there in the mixture? 

If 48 ounces of gravity cream had been used, there would 
be in the mixture 16 per cent, of fat. But only 9 ounces of 
gravity cream has been used. 

Therefore ^ of 16 = 3 per cent. fat. 

Second Step. — How much protein is there in the mixture? 

If the sum of the number of ounces of gravity cream and 
skimmed milk used equaled 48, then there would be 3.20 per 
cent, of protein in the mixture, as gravity cream and skimmed 
milk each contain 3.20 per cent, protein. 

But only 9 ounces of cream and 21 oimces of skimmed milk 
were used, equaling 30 oimces. 

Therefore ff of 3.20 = 2 per cent, protein. 

Third Step. — ^How much sugar was put in with the cream 
and skimmed milk? 

If the sum of the number of ounces of gravity cream and 
skimmed milk used equaled 48, then there would have been 
put in 4.50 per cent, sugar, as gravity cream and skimmed 
milk each contain 4.50 per cent, sugar. But only 9 ounces of 
cream and 21 ounces of skimmed milk were used, equaling 30 
ounces. 

Therefore ft of 4.50 = 2.8 per cent, sugar. 

Fourth Step. — ^What percentage was added by the 4 level 
tablespoons of milk-sugar used? 

One level tablespoonful of milk-sugar added to a 48-ounce 
mixture raises the sugar percentage 0.80 per cent. Therefore 
3.2 per cent, of dry milk-sugar was added, which plus the 2.8 
per cent, already in the milk and cream used = 6 per cent. 



200 PRACTICAL INFANT FEEDING 

total sugar. The formula contains, then, fat, 3 per cent.; sugar, 
6 per cent. ; protein, 2 per cent. 

These principles of calculation apply to any formula, no 
matter what its ingredients are, and it is possible by their use 
to calculate the strength of any mixture that is being used 
without any tables or algebraic equations. 

They are, however, so much more complicated than the first 
method given, that one would not care to use them, and they 
are included here rather for reference than for actual use. 



CHAPTER VIII 
SPECIAL PREPARATIONS USED IN INFANT FEEDING 

As Dr. Rachford, of Cincinnati, has so wisely said, the 
various preparations used in infant feeding are the "tools of 
the trade," and just as an artisan selects one particular tool 
for a special purpose, so does the physician have at his com- 
mand a variety of special preparations which he can use with 
advantage in certain cases. In general, it is well to employ 
the ordinary milk modifications if possible, but many times for 
special indications other preparations have to be used. 

Fat probably causes more trouble to the baby than any 
other one of the food elements, but there are few practical 
ways in which it can be changed to make it more digestible for 
him. 

Eomogenization. — If milk is driven by means of a powerful 
pump through a finely ground agate valve (homogenizing ma- 
chine) the fat globules are broken up into innumerable smaller 
ones, and a much more perfect emulsion is obtained. Babies 
who have difficulty in taking care of fat will sometimes digest 
milk prepared in this way much better, the probable explana- 
tion being that the digestion and absorption of the fat is greatly 
facilitated by the fineness of the emulsion. Inasmuch as homo- 
genized milk is available only in large centers where there are 
milk laboratories, this method of feeding is at present not 
practical. 

The Use of Other Fats in Place of Butter Fat. — ^The fat of 
cow's milk is not a particularly easily digestible fat for a number 
of reasons, as we have seen. Therefore if any fats can be found 
which are more digestible it is not unreasonable to use them 



202 PRACTICAL INFANT FEEDING 

in infant feeding, in combination with cow's milk from which 
all the fat has been removed. 

Olive oil is an easily digestible fat of good food value, and 
has a definite place in infant feeding. In general, the simpler 
a fat is chemically, and the lower melting-point it has, the 
easier it is of digestion and absorption. OHve oil is much more 
simple chemically than butter fat, its melting-point is low, 
and the soaps which are formed from it in the infant's intestine 
are more soluble and easy of absorption than most of the soaps 
formed from the acids in butter fat. Therefore olive oil should 
theoretically be a fat easy of digestion and absorption, and in 
practice this is found to be true. OHve oil may be given in 
either one of two ways: 

(a) By simply putting the baby on a fat-free milk modifica- 
tion, and then feeding a sufiicient quantity of olive oil by the 
spoon. A teaspoonful of oHve oil weighs about 5 grams and 
contains about 45 calories. A liter of cow's milk with 4 per cent, 
of fat contains 40 grams of fat. 'From this an approximate 
idea may be obtained of how much olive oil to give. This is a 
practical way of substituting another fat for butter fat, and 
is sometimes of real value in infant feeding, and in the feeding 
of older children as well. 

(b) Homogenized Olive Oil. — By this is meant a combina- 
tion of a fat-free milk mixture with a certain amount of olive 
oil, which has been run through the homogem'zing machine. 
By this means a very fine and smooth emulsion of olive oil 
with the milk is made, and the oil appears to be homogeneously 
mixed with the milk. The virtue of such a preparation as this 
probably lies partly in the fact that oHve oil is an easily digestible 
fat anyhow, and that the very fine emulsion makes it still more 
so. This method of feeding was first advocated by Dr. May- 
nard Ladd, and it undoubtedly produces marvelous results in 
some cases. Other cases do not do so well. Although it is a 
real weapon with which to combat troubles of fat digestion in 
selected cases, it is not practical for general use, as homogenized 
milk can be obtained only in the large cities. Dr. Ladd tells 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 203 

me that he has recently had the Walker- Gordon Company 
put up homogenized oil in a 32 per cent, emulsion with acacia. 
This is bottled, can be shipped to any distance, and will keep 
indefinitely. It is added to fat-free milk combinations in exactly 
the same way that ordinary cream would be added, and mixes 
perfectly with the milk. This should put the use of homogenized 
oil on a practical basis. 

The Use of Synthetic Fat Mixtures Prepared to Resemble 
the Fat of Human Milk, — It is theoretically possible to prepare 
a milk the fat of which shall be chemically very similar to that 
of human milk, that is, with the same volatile fatty acid content, 
melting-point, etc. Dr. Gerstenberger, of Cleveland, has been 
working on this problem for a number of years, and has prepared 
a milk which he calls "synthetic milk adapted"^ C'S. M. A.'O- 
The fat of this milk is prepared from 

Per cent. 

Tallow oil to 10 

Cocoanut oil about 15 

Cocoa-butter about 20 

Cod-liver oil 10 

Tallow 55 to 45 

According to Gerstenberger very satisfactory results have been 
obtained by the use of this milk. Such experiments as this 
are of the utmost value theoretically, and undoubtedly in the 
future will be of practical importance. At the present time 
the lack of availability of such a preparation puts it outside 
the limits of practical use for the majority of pediatrists.^ 

Summary. — Other fats, such as homogenized olive oil and a 
synthetic fat preparation made to resemble the fat of human 
milk, may in certain difficult feeding cases be substituted for 
butter fat with good results. Practically speaking, however, 
in most communities the only way that the fat in an infantas 
diet can be changed is to substitute olive oil, fed by the spoon. 

» Amer. Jour. Dis. Chil., vol. 10, p. 249, 1915. 

2 Since this was written *'S. M. A." has been put on the market in pow- 
dered form by the Laboratory Products Co., Cleveland, Ohio. 



204 PRACTICAL INFANT FEEDING 

Although the other methods of altering the fat in the food 
are not now practical for general use, their principle is sound 
and they open up a field of speculation which may some time 
be very profitable. There is no question that the chemical 
peculiarity of butter fat is one of the most important stumbling- 
blocks in infant feeding. It seems not at all unreasonable to 
expect that in the future there may be a practical method which 
will be of general use in substituting for butter fat fats of more 
easy digestibility. 

Sugar. — ^There are four sugars which may be used in infant 
feeding: 

1. Lactose (milk-sugar) 

2. Sucrose (cane-sugar) Disaccharids. 

3. Maltose (malt sugar) 

4. Dextrose (grape sugar) — Monosaccharid. 

Lactose is the sugar most commonly employed, and is the 
best one to use as a routine. It is rather easily fermentable, 
and its assimilation limit is not as high as that of maltose. 
This latter is, however, of little practical importance. The vast 
majority of healthy babies can be fed satisfactorily with lactose 
as the sugar, but if there is a tendency to fermentation, it should 
be omitted, and a maltose-dextrin preparation substituted. 

Sucrose. — The advantage of sucrose is its cheapness, other- 
wise it has no particular advantage over lactose. Lactose is 
expensive, and the difference in price may mean a good deal 
to a poor family. If it does, it is best to use cane-sugar instead 
of lactose. The only disadvantage that it possesses is that on 
account of its sweet taste it may develop too great a liking for 
sweets in the baby, and it may be difficult thereafter to get him 
to take cereal, etc., unless it is sweetened. It has about the 
same assimilation limit and ease of fermentation as lactose. 

Maltose. — ^By "maltose" we do not mean pure malt sugar. 
We mean a mixture of dextrins and maltose. Pure maltose 
is more of a chemical curiosity than anything else; it is very 
expensive, difficult to prepare, and if it is used is likely to cause 
diarrhea. The maltose-dextrins preparations are prepared by 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 20$ 

the use of barley malt. Barley malt is nothing more or less 
than grains of barley which have been kept in a warm, wet 
place until they sprout. These barley grains contain a ferment- 
diastase which is capable of breaking down starch into sugar. 
The barley malt is mixed with a certain amount of starch 
(wheat, potato, or cornstarch usually), and the starch is broken 
down by the ferment into maltose and dextrins. 

Starch plus barley malt 

Dextrins 

i 
Maltose 

The resulting product consists partly of dextrins and partly 
of maltose. Malt sugar has been used a great deal of late owing 
to the emphasis that the Finkelstein school has laid upon lactose 
fermentation. Malt sugar has a higher assimilation limit than 
milk-sugar, that is, a baby can take more of malt sugar with- 
out showing sugar in the urine than he can of lactose. The 
assimilation limit of lactose and sucrose is about 3.5 gm. per 
kilogram of body weight, that of maltose, about 7 gm. Although 
this point has been made a good deal of by those who advocate 
the routine feeding of maltose, in reality it is not a very impor- 
tant point, as one would practically never feed a normal baby 
enough sugar of any sort to cause it to appear in the urine. 
There seems to be no question that maltose is less fermentable 
than lactose, and this, indeed, is its chief value. If a baby 
has a tendency toward loose, acid stools, it is always well 
to substitute a maltose preparation for lactose. It must be 
remembered, however, that maltose, while it does not fer- 
ment quite so readily as lactose, nevertheless does ferment, 
and that the simple substitution of maltose for lactose is by 
no means a cure for most sugar troubles. The maltose prepara- 
tions, particularly those containing large amounts of maltose, 
are likely to cause spitting up; if they do so, they should be 
discontinued and sucrose or lactose substituted. The malt 
sugar preparations contain varying amounts of maltose and 



2o6 PRACTICAL INFANT FEEDING 

of dextrins, and, in general, those with much maltose and little 
dextrins are laxative, while those which contain much dextrin 
and relatively little maltose are somewhat constipating. The 
liquid maltose preparations are especially laxative, and the 
addition of a small amount of such a preparation as Maltine 
Malt Soup to the milk mixture sometimes works wonders for 
a constipated baby. Also in cases of chronic fat indigestion 
with dry soapy stools the addition of a maltose-dextrin prepara- 
tion with a high maltose content often does a great deal of good. 
As a summary it may be said that the indications for the 
use of a maltose-dextrin preparation are as follows: 

1. If there is any tendency to sugar fermentation, use a 
preparation with a high dextrin and relatively low maltose 
content, as Meade's dextrimaltose. 

2. For constipation: Add two or three tablespoonfuls of a 
liquid maltose preparation to the day's feeding in addition 
to the other sugar already there. Or substitute one of the dry 
maltose-dextrin preparations, such as Mellin's Food or Bor- 
cherdt's Malt Sugar, for the sugar already there. 

3. For chronic fat indigestion with dry, clay-colored, soapy 
stools use a liquid maltose preparation in combination with 
lactose and starch. 

4. If it is desired to feed an unusually large amount of sugar 
to a baby, it is well to use a maltose-dextrin preparation, as in 
this way there is less danger of bringing about sugar fermenta- 
tion than if lactose were used. 

The contraindications for the maltose preparations are these: 

1. Spitting up. 

2. Special idiosyncrasy to maltose. 

In the past few years a good many maltose-dextrin prepara- 
tions have been put on the market. Some of these are liquids, 
some solids, some contain large amounts of maltose and small 
amounts of dextrins, or vice versa; some are useful for one 
purpose, some for another. Most of them have a certain amount 
of potassium carbonate added in order to neutralize the excessive 
acidity of the malt present. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 



207 



Composition of Malt-sugar Preparations 



Meade's Dextrimaltose No. 1 

Per cent. 

Maltose 52 

Dextrins 41 

Sodium chlorid 2 



Meade's Dextrimaltose No. 2 

Per cent. 

Maltose 53 

Dextrins 42 

Meade's Dextrimaltose No. 3 

Per cent. 

Maltose 52 

Dextrins 41 

Potassium carbonate 2 



Borcherdt's Malt Soup Extract * 

Per cent. 

Maltose 55 

Dextrins 12 

Protein 6 

Potassium carbonate 1.1 

Borcherdt's Drimalt Soup Extract 
Per cent. 

Maltose 71 

Dextrins 13 

Protein 9 

Borcherdt's ''Malt Sugar" 

Per cent. 

Maltose 87 

Dextrins 5 



Horlick's Food 

Per cent. 

Maltose 64 

Dextrins 17 

Protein 12 

Fat 1.4 



Horlick's "Diastoid" 

Per cent. 

Maltose 73 

Dextrins 11 



''Maltine" Malt-Soup Extract ^ 

Per cent. 

Maltose 62 

Dextrins 3 

Mellin's Food 

Per cent. 

Maltose 58 

Dextrins 20 

Protein 10 

Fat 0.16 

Potassium bicarbonate .... 2.5 



''Malt 5ow/?."— Keller's "Malt Soup," which was originally 
introduced by Liebig in 1865 and later reintroduced and some- 
what modified by Keller in 1898, is often of considerable value 
when it is desirable to offer a low fat percentage in combination 
with a high carbohydrate content in an easily assimilable form 
(see Chronic Fat Indigestion). It is often possible to feed to a 
baby a larger amount of carbohydrate if several different forms 
of carbohydrate are used, than if only one is employed. The 
reason for this is that the various carbohydrates are absorbed 
with different degrees of rapidity, and therefore if we offer a 

1 Liquids of the consistency and appearance of molasses. 



208 PRACTICAL INFANT FEEDING 

mixture containing several carbohydrates, some of which are 
broken down and absorbed rapidly, some slowly, there is not 
so much likelihood of a large amount of fermentable carbohy- 
drate being free in the intestine at one time. Malt soup is 
especially indicated where there is lowered fat tolerance, or in 
any case when it is desirable to feed a high carbohydrate 
percentage. 

It is usually prepared as follows: 

Four tablespoons of liquid malt soup extract are dissolved in 
22 ounces of warm water. 

Five and a half level tablespoons of wheat flour are rubbed up 
in a little milk to make a thin paste, then more milk is added up 
to 11 ounces. The mixture of flour and milk is strained through 
a fine sieve. Mixture No. 1, containing the malt extract, is 
then added to mixture No. 2, and the whole boiled in a double 
boiler for ten minutes. Water is then added to make 33 ounces. 
The resulting mixture contains four different carbohydrates — 
lactose, maltose, dextrins, and starch — and has the following per- 
centage composition: 

Per cent. 

Fat 1.25 

Carbohydrate 12. 00 

Protein 2.00i 

There are at present at least two preparations on the market 
in which the malt extract is in a dry form and is mixed with 
wheat flour all ready for mixing with milk. Analyses of these 
are as follows: 

Borcherdt's Dry Malt Soup Extract Mead's Dry Malt Soup Extract with 
with wheat flour. wheat flour. 

Per cent. Per cent. 

Maltose 46. 8 Maltose v An 



Dextrins 9.4 Dextrins 

Starch 31.1 Wheat flour 47 

Protein 8.2 Potassium carbonate 1 

Ash 2.2 Moisture 5 

Moisture 2.3 

1 Part of the protein is vegetable protein from the wheat flour. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 209 

The same principle — i. e., low fat and high polycarbohy- 
drate feeding — can, of course, be used without making up the 
malt soup according to the usual formula, and it is often desirable 
to vary it considerably to fit the needs of the individual baby. 
Any milk mixture with a low fat content which has malt extract 
and a cereal diluent added to it and is then boiled is, in reality, 
a malt soup. The principle of low fat and high poly carbohy- 
drate feeding is a most excellent one, and will be found useful 
in many cases. It will usually be found best, however, to apply 
the principle in accordance with the individual baby one is 
dealing with, rather than to follow any set rule for making the 
malt soup. 

Dextrose. — Whereas the sugars that we have been discussing 
are disaccharids or comple sugars, dextrose is a monosaccharid 
or simple sugar. While it is necessary for the disaccharid to be 
broken down into monosaccharids before they can be absorbed, 
dextrose is absorbed without further change. This would seem 
to make dextrose an ideal sugar for feeding where quick absorp- 
tion is desired. It is very easily fermentable, and on this account 
has been used only very little in practical infant feeding. Mar- 
riott^ in 1919, however, advocated the use of corn syrup con- 
taining dextrose in combination with lactic acid milk, on the 
grounds that it would probably be absorbed when given in this 
combination before it could be attacked by the intestinal bacteria 
and broken down. He used commercial com syrup, which 
contains p^,,^t. 

Maltose 20 

Dextrose 15 

Dextrin " 32 

Cane-sugar 3 

This is used by mixing 45 volumes of the syrup with 55 volimies 
of water, which gives a thin syrup; 100 c.c. of this contains 
approximately 50 gm. of carbohydrate. This was added to 
lactic acid milk by Marriott in some cases, so that the total 
carbohydrate in the mixture was as high as 10 to 15 per cent. 
1 Jour. Amer. Med. Assoc, vol. 13, No. 16, 1919. 
14 



2IO PRACTICAL INFANT FEEDING 

It is surprising to see how much carbohydrate can often be taken 
in this way without fermentation occurring. 

This method of feeding is recommended by Marriott espe- 
cially for severe cases of malnutrition. The chief difficulty in 
dealing with these babies is that they need more food than the 
normal baby, and still have a very much diminished digestive 
power. Any food which is high in caloric value and still not 
easily fermentable would seem to be an ideal food upon which 
to feed them. The lactic acid milk and com syrup mixtures 
seem to fulfil these indications. It is, in reality, much the same 
principle as that involved in malt soup, a polycarbohydrate food 
with which it is possible to enable the baby to absorb and burn 
large amounts of carbohydrate without much danger of intes- 
tinal fermentation. It is often of considerable value in older 
children with chronic intestinal indigestion (see Chapter XI). 

Starch. — It has been shown many times that even new- 
born babies have the power of digesting starch. Practically 
speaking, however, starch is not ordinarily included in the diet 
until the sixth or seventh month, although for special indications 
it may often be used earlier than this. It is often of advantage 
to substitute a cereal diluent for water in the milk modification 
where it is desired to add more carbohydrate to the diet, but 
not in the form of sugar. From i to 1 per cent, of starch is 
easily tolerated by most babies over four or five months old, 
and starch being not easily fermentable, may often take the 
place of an equivalent amount of sugar in the diet if the sugar 
tolerance is low. A cereal diluent added to the mixture also 
makes the casein curd more digestible. The most common 
cereal diluents used are barley-water or oat-water. 

Barley- or Oat-water. — Mix 1 rounded tablespoon of Robin- 
son's, Brooks', or Meade's barley flour with 1 pint of water in a 
double boiler. Boil one-half hour. Add enough water to make 
up for what has been boiled away, and strain. The resulting 
gruel contains about 1.50 per cent, of starch. The same direc- 
tions are followed for oat-water, using oat flour, prepared groats, 
or oatmeal itself. Oatmeal-water has a slight laxative action. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 211 

Barley or Oat Jelly. — In making barley or oat jelly use a 
well-rounded tablespoon of prepared barley or oat flour to 
about 8 ounces water. Cook in a double boiler for three- 
quarters of an hour. Salt and strain. The resulting product 
should be just too thick to run, but not so thick as a cereal 
would be when used in the adult dietary. If oat jelly is made 
from oatmeal instead of oat flour it should be cooked three 
hours, and strained through a colander to get rid of all coarse 
particles. 

Protein. — The Curdling of Milk by Rennin. — ^The milk- 
curdling enzymes of the gastric juice split the casein through a 
process of hydrolytic cleavage into soluble paracasein and a 
peptone-like body. The soluble paracasein then forms a com- 
bination with the soluble calcium salts of the milk and an 
insoluble curd of paracasein results. Practically all the fat in 
the milk is entangled in the meshes of the casein curd and pre- 
cipitated also. The curd consists then of all the casein, the fat, 
and most of the calcium salts. The whey, or fluid that is left 
contains the lactose, lactalbumin, and the rest of the salts 
(mostly sodium and potassium salts). Inasmuch as the curd 
formed from cow's milk in the infant's stomach is of tough, 
leathery consistency, and is difficult of digestion, it is often 
desirable to do something to the milk mixture so that a soft and 
flocculent curd will result, more resembHng that of human milk. 
This may be brought about in a number of ways : 

1. Simple dilution of the milk mixture by decreasing the 
concentration of the casein and calcium tends to make a softer 
curd. 

2. Boiling the milk makes a softer curd, probably due to the 
fact that a considerable amount of the calcium salts are precipi- 
tated by boihng. In order to bring this about the milk should 
be boiled ten minutes if in a double boiler, and three to five 
minutes if boiling vigorously over the free flame. 

3. By adding a cereal diluent, such as barley- or oat- water. 
In order to secure the best results the mixture should contain 
about 0.75 per cent, of starch. This method is not so efficient 



212 PRACTICAL INFANT FEEDING 

as some of the others, but may be used in combination with 
them. 

4. By adding an alkali, which hinders curd formation, as 
rennin does not work in an alkaline medium. Three alkaHes 
are in ordinary use: 

Lhne-water. — If Kme-water is used it must be used in amounts 
equal to at least 25 per cent, of the milk or milk and cream in 
the mixture. Any less amount does no good. If lime-water in 
amounts equal to 50 per cent, of the milk or milk and cream is 
added, gastric digestion is almost totally inhibited. 

Sodium Citrate. — In practice this is easier to use than lime- 
water, as it is less bulky, and is probably just as efficient. 
Either 1 or 2 grains of sodium citrate is used to each ounce of 
milk or milk and cream in the mixture. What I ordinarily do 
is to give a prescription containing about 20 grains of sodium 
citrate to the teaspoonful of water, and then direct that either 
1, 2, or 3 teaspoonfuls, as the case may be, be added to the 
day's milk supply. 

I^. Sodium citrate §ij ; 

Water ad. § viij. — M. 

S. — Add 2 teaspoonfuls to the day's feeding. 

This would give 40 grains of sodium citrate, and would be 
suitable for a modification containing from 30 to 40 ounces of 
milk. 

Soda Bicarbonate. — This is used in the same strength as 
sodium citrate, but has the disadvantage that it may upset the 
stomach. It also causes an unpleasant taste in the milk. 

5. Peptonization. — By predigestion of the casein of the milk 
before the baby takes it curd formation can be prevented. This 
is a rather laborious process, however, and the other ways of 
making a soft curd are so much more simple that it is not much 
used now. Peptonized milk may sometimes be valuable for 
very weak babies or for rectal feeding, however. The best way 
to peptonize milk is as follows: Dissolve the contents of a 
"peptonizing tube" in 8 tablespoonfuls of warm water. Add a 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 213 

tablespoonful of this solution to the feeding when it is removed 
from the ice-chest, and warm it by immersing the bottle in hot 
water for about fifteen minutes, in the same way as when an 
ordinary feeding is given. The feeding should then be given 
immediately. 

6. By inoculating the milk with lactic acid bacilli the protein 
is precipitated in fine flakes as "lactate of casein," and does not 
coagulate again in the stomach (see Lactic Acid Milk) . 

7. Whey Mixtures. — In the early days of scientific infant 
feeding, when the casein of cow's milk was supposed to be 
extremely difficult of digestion, whey mixtures, that is, mixtures 
made with whey and gravity cream, in order to get rid of the 
casein, were used a great deal. At the present time we beheve 
that casein, when given in suitable amounts, and particularly 
if the milk is boiled, causes very Httle trouble. Whey mixtures 
are, therefore, but little used. They may be useful occasionally 
for newborn, premature, or very weak babies, or for babies who 
vomit. They should never be used if there is a tendency to 
diarrhea. 

Preparation of Whey. — To 24 ounces of warm (100"^ F.) 
skimmed milk add 2 teaspoonfuls of essence of pepsin and stir. 
Let it stand until it has jellied, break up the curd with a knife, 
and strain through cheese-cloth. If the whey is to be used in 
combination with cream it should be heated to 160° F. in order 
to destroy the ferment, as if this is not done the casein of the 
cream will be curdled by it. Whey contains: 

Per cent. 

Fat 0.00 

Lactose 4. 50-5. 00 

Whey protein 0. 90 

Salts 0.80-0.90 

Lactic Acid Milk. — By lactic acid milk is meant a milk 
"soured" with bacilli of the lactic acid group. It may be pro- 
duced naturally, as in butter making, or artificially, by adding 
a culture of lactic acid bacilli to the milk and allowing it to 
incubate. 



214 PRACTICAL INFANT FEEDING 

Lactic acid milk has been used to a certain extent for a long 
time in infant feeding, its use probably originating in Holland, 
but it is only in the last few years that it has been employed 
extensively. The lactic acid bacillus when introduced into 
milk multiples very rapidly, and produces lactic acid fermenta- 
tion of the milk-sugar, with the formation of a considerable 
amount of lactic acid. When the acidity has reached a certain 
degree the casein of the milk is precipitated in fine flakes. 
Lactic acid milk is usually made from fat-free milk, or from milk 
containing very small amounts of fat, and during the process of 
fermentation the sugar content is, of course, reduced considerably. 
It is then a food low in fat, low in sugar, and containing a vary- 
ing amount of lactic acid, together with enormous munbers of 
lactic acid organisms. It is also relatively high in protein, in an 
easily assimilable form, for inasmuch as the casein has been 
once precipitated it does not coagulate again in the stomach. 
Commercial buttermilk varies somewhat in composition, but is 
usually about as follows: 

Per cent. 

Fat 0.50-1 

Sugar 3.75-4 

Protein 3.50 

The artificially made preparations have approximately the 
same composition. The use of lactic acid milk is founded upon 
its ability to reduce intestinal fermentation and putrefaction 
owing to the flooding of the intestine with lactic acid bacilli, 
which are antagonistic to and suppress the growth of the harmfxil 
organisms present. Also the fact that it contains a low fat and 
sugar and a relatively high protein is of considerable importance 
when it is used as a corrective diet in cases of sugar fermenta- 
tion. It has a great deal of use in infant feeding, particularly 
as a diet in the diarrheal diseases of infancy, and also in cases 
of chronic intestinal indigestion in older children. 

It is best, if possible, to use an artificially made preparation 
rather than the natural buttermilk, as the age and purity of 
the latter are often doubtful, and it may be infected with 



SPECIAL PREPARATIONS USED IN INPANT FEEDING 215 

undesirable organisms in addition to the desirable lactic acid 
bacillus. 

Lactic acid milk may be easily prepared in the home from 
any one of the liquid cultures that are now on the market. In 
the late afternoon the contents of a culture-tube is mixed with 
the milk, and allowed to stand over night, preferably in a warm 
place. The next morning the lactic acid milk is ready. If the 
fermentation has not been carried too far, there will be no 
separation of the curd and whey; if it has been carried too far, 
it is excessively sour, bubbly, and the curd and whey become 
separated. If this occurs, less of the culture should be used and 
the milk allowed to stand in a somewhat cooler place. 

If desired, up to 2 per cent, fat may be used with lactic acid 
milk, but it is not well to attempt to use more than this, as 
sometimes with even this amoimt the resulting product is too 
thick and slimy. 

Babies under six or seven months of age usually take lactic 
acid milk preparations as readily as any other milk, but older 
babies, particularly those over a year old, are likely to refuse it 
for the first few feedings. It is rare indeed, however, to find a 
baby who cannot be made to take it eventually. It should be 
offered at regular intervals, every three or four hours, as the 
case may be, and after several refusals the baby fiinally gets so 
hungry that he is glad to take anything he can get. If after forty- 
eight hours of persistent forcing he still refuses to take it, it is 
usually advisable to give up and use some other method of feeding. 

Protein Milk ("Eiweissmilch" ; Albumin Milk).— The best 
term for this preparation is "protein milk.'' The words "eiweiss" 
and "albumin" are misnomers, as the getting rid of the whey 
protein (albumin), with its salts, is one of the objects of the 
milk. The purpose of protein milk is to supply a food low in 
sugar and high in protein (casein) in an easily assimilable form. 
It was devised by Finkelstein in 1910, and since then has been 
used by thousands of physicians all over the world. It is of 
especial value in cases of sugar fermentation, and is one of the 
best weapons we possess in dealing with this type of case. It is 



2l6 PRACTICAL INFANT FEEDING 

not a universal food for all types of feeding cases, it is not a food 
to be fed to normal babies, it is not a food to feed to any baby 
over a long period of time. Its value is due to the fact that it 
alkalinizes the intestine very quickly, and by the withdrawal of 
fermentable carbohydrate and the substitution of a relatively 
large amount of casein in an easily digestible form, plus calcium, 
conditions are created which favor the production of pasty or 
formed soapy stools. 

Protein milk is prepared as follows : 

To 1 quart of whole milk in a saucepan add 2 teaspoons of 
Fairchild's Essence of Pepsin. Let it stand at blood heat for 
about half an hour, then break up the curd gently with a knife, 
transfer the whole to a cheese-cloth bag, and allow the whey to 
strain off (usually let it strain one hour). Then rub the curd 
through a fine wire sieve with a potato-masher into a pint of 
fat-free lactic acid milk or buttermilk, and make the total 
mixture up to 1 quart by the addition of water. It is essential 
that the curd be in a very finely divided form, and in order to 
attain this it is usually necessary to rub it through the sieve 
several times. 

The final product contains: fat, 2.5 per cent.; sugar, 1.5 
per cent. ; protein, 3 per cent. ; salts, 0.50 per cent. Dextrimaltose 
should be added up to about 3 per cent., as it may be dangerous 
to feed too low a sugar. 

The protein furnished to the mixture by the buttermilk is 
in a finely divided, precipitated form, as is also that furnished 
by the rubbed curd, so that it cannot be curdled again in the 
stomach, and therefore offers the possibility of feeding a large 
amount of casein in an easily digestible form. This preparation 
should be warmed very slowly and slightly before being given to 
the baby, as, if it is heated too hot, clumping of the curd and 
separation of the whey of the buttermilk will result. 

While it is true that protein milk is of very great usefulness, 
it is rather difficult of prepartion. It can be made satisfac- 
torily by intelligent mothers, but there is absolutely no use in 
trying to employ it in the ordinary out-patient type of case. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 217 

The principle of low sugar and high casein for certain cases is a 
very sound one, and every physician who has babies in his 
practice should have at his command some method of putting 
together such a mixture, but the difficulty of preparation deters 
many men from using this most valuable principle. Let us 
consider some of the other and more simple ways in which a 
low sugar and high casein milk of the same general character as 
protein milk may be obtained. 

1. In any city where there is a milk laboratory it is best to 
have one's high protein milk made at the la,boratory. This has 
the additional advantage that it is not necessary to use the same 
stock formula for each case, and more individualization is 
possible. In the laboratory protein milk is made from cream, 
precipitated casein, and water, the whole then being run through 
the homogenizing machine in order to secure a smooth mixture. 
The directions to the laboratory would be given as follows: 
Fat, 2 to 2.50 per cent. ; sugar up to 3 per cent. ; precipitated casein 
up to from 2 to 3.5 per cent., depending upon the age of the baby. 
In such a mixture as this we would not get the value of the lactic 
acid bacilli that are in the buttermilk of the original preparation, 
but if this is desired it is easy enough to have the whole inocu- 
lated with the desired organism. The sugar is very low (unless 
sugar is added), the only sugar present being that which comes 
from the small amount of cream used to get the desired percentage 
of fat, and if a heavy cream is used, this is almost negligible. 
Suppose we wished 2 per cent, of fat in a 32-ounce mixture, and a 
32 per cent, cream were used. Only 2 ounces of cream would be 
required, and this would furnish only about 0.30 per cent, of 
sugar to the mixture. It is, however, not necessary to get the 
sugar as low as this, and it is even dangerous, so it is usually 
best to make up these mixtures with an ordinary gravity cream, 
and to add dextrimaltose up to about 3 per cent. This is by far 
the most satisfactory way of using the high casein and low 
sugar principle if one lives in a big city where there is a milk 
laboratory. Naturally, it is not available for those living in the 
country or in smaller cities or towns. 



2l8 PRACTICAL INFANT FEEDING 

2. Dried Protein Milk. — There are two preparations of dried 
protein milk on the market which when mixed with water give 
about the same percentage composition as the original Finkel- 
stein preparation. One of these is put up by Louis Hoos, of 
Chicago, the other by the Canadian Milk Products Co., of 
Toronto. Although I cannot vouch for the value of these 
preparations from personal experience, having never had occa- 
sion to use them, there seems no reason why as good results 
could not be obtained with them as with the home-made protein 
milk, and they should, on account of their ease of preparation in 
the home (simply mixing with water), be a practical and valuable 
way of applying the low sugar and high protein principle. 

Dried Casein Plus Whole Milk or Buttermilk and Water. — For 
general use in smaller towns and cities, and with patients who 
would not have intelKgence to carry out any compHcated pro- 
cedure, the addition of dried powdered casein to dilutions of 
whole milk, skimmed milk, or buttermilk offers a very easy and 
satisfactory practical way of using the high protein and low 
sugar principle. In the summer of 1915 I fed between 40 and 
50 cases of fermentative diarrhea in this way, and secured 
excellent results, fully as good, I believe, as could have been 
secured by the use of any other high protein milk. The prepa- 
ration used was ''Larosan." It is a calcium casein preparation, 
and is made from dried pure casein to which 2.5 per cent, of 
calcium oxid has been added. The powder is semisoluble, and 
can be mixed with gravity cream mixtures or with whole or 
skimmed milk mixtures, in any proportion desired. The usual 
method of mixing it is as follows: 

Mix one small f -ounce package in 6 ounces of cold milk, and 
add this to 10 ounces of whole milk which is at the boiling 
temperature. Boil five minutes, with constant stirring; this 
should make a thin and fairly smooth gruel. To this gruel add 
1 pint of water. The resulting mixture contains : Fat, 2 per cent. ; 
sugar, 2.20 per cent.; protein, 3.40 per cent. 

It is, of course, not necessary to use this preparation in 
accordance with these directions, and this is one of its chief 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 219 

advantages, that one can add as much or as little of it as neces- 
sary to any sort of milk mixture to secure any percentage of 
protein desired. If i-ounce (one-half package of Larosan) is 
added to a 32-ounce milk mixture approximately 1 per cent, of 
protein is added. The same amount added to a 48-ounce mix- 
ture adds 0.75 per cent, protein. One-quarter of a package 
(i ounce) added to an 8-ounce mixture adds 2 per cent, protein. 

Two other dried casein preparations that have recently been 
put on the market are "Casec" and ''Aprotein." The former is 
a calcium caseinate, the latter a sodium caseinate.^ 

Dry Milk Powders. — In the last few years dried milk feeding 
has had many advocates. The two brands of dried milk that 
have been used most extensively are the ^'Dryco Brand" and 
"Klim." 

The ''Dryco Brand" contains: 

Per cent. 

Fat 12 

Lactose 44 

Protein. 34 

Salts 7 

**Klim" dried milk is prepared in two forms, the "skimmed" 
and the "whole.": 

"Skimmed" dried milk. "Whole" dried milk. 

Per cent. Per cent. 

Fat 1.35 Fat 28 

Lactose 50. 00 Sugar 38 

Protein 38. 00 Protein 26 

Salts 0. 00 Salts 5 

Dried milk undoubtedly has a definite place in infant feeding. 
It has come to stay, and while I by no means agree with those 
who would use it in the majority of their difficult feeding cases, 
there is no question that it sometimes works remarkably 
well. It contains (Dryco) a low fat, relatively low sugar, and a 
high protein in an easily assimilable form, which is not coagu- 
lated in the stomach. It sometimes works very well in cases 
of fat intolerance, of sugar fermentation, and also with vomiting 
* Since this was written "Protolac" has also appeared. 



220 PRACTICAL INFANT FEEDING 

babies. It is also naturally of great value for traveling, or in 
any locality where clean breast milk cannot be obtained. It 
should be a godsend to the South in the summer. 

One level tablespoonful of Dryco to 1 ounce of water gives a 
mixture containing fat, 1.50 per cent.; sugar, 5.50 per cent.; 
protein, 4 per cent. 

It is most often used in this proportion, but for babies with 
weak digestive powers, especially in starting, it is best to begin 
about half -strength, and then gradually work up. It contains 
16 calories to the level tablespoon, and in order to supply a 
baby with 50 calories per pound per day it is necessary to use 
3 level tablespoons per day for each pound of body weight 
(Dennett^). If it is desired to increase the carbohydrate con- 
tent, milk-sugar or dextrimaltose may be added, or it may be 
advantageously combined with barley-water if it is desired to 
feed starch. If more fat is wanted, "Klim" can be used instead 
of "Dryco," as when whole "Klim" dried milk is mixed with 
water in the proportion of 1 level tablespoon to 2 ounces of water, 
the formula is almost exactly that of whole cow's milk — 3.5 
per cent, fat; 4.7 per cent, sugar, and S.3 per cent, protein, with 
a caloric value of 20 to the ounce (Root^). Babies that are fed 
on dried milk are very likely to have a strongly ammoniacal 
urine. If this occurs, it can usually be done away with by 
adding carbohydrates to the mixture. 

Goat's Milk. — There is probably no special advantage of 
goat's milk over cow's milk, although this has been claimed by 
some writers. Goats are practically immune to tuberculosis, 
and I remember a woman who bought a goat simply because 
she was afraid her baby might develop it. The chief use that 
goat's milk has is as a food for babies who have an anaphylactic 
idiosyncrasy to cow's milk. For such cases it is a godsend! 

Usually no cream rises on goat's milk, probably due to the 
small size of the fat globules. It has been found by Schultz and 
Chandler that 91 per cent, of the fat globules of goat's milk are 

1 New York State Jour. Med., July, 1918. 

2 Charlotte Med. Jour., May, 1920. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 221 

under 4 microns in diameter, and over half of these are under 2 
microns. In cow's milk 90 per cent, of the globules are over 
4 microns. The fat globules of goat's milk possess, therefore, a 
much greater surface are than those of cow's milk, and thus 
offer a larger surface for the action of the digestive juices. 

A goat will usually produce from 12 ounces to 3 quarts of 
milk a day, and its average composition, which is not much 
different from cow's milk, is as follows: 

Per cent. 

Fat 3.8 

Sugar 4.50 

Protein 3. 10 

Salts 0.85 

The casein precipitates in the form of a tough, hard curd. It 
differs from cow's milk, in that it is of an almost pure white 
color. It is not always easy to get a goat, or to board him after 
he is obtained, and for this reason a preparation of evaporated 
goat's milk^ is often of considerable service. It looks very much 
like ordinary evaporated cow's milk, and has the following 
composition: 

Per cent. 

Fat 8.50 

Protein 7.30 

Lactose 9. 00 

Ash 1.60 

One-third of the evaporated milk and two- thirds water gives: 

Per cent. 

Fat 2.60 

Lactose 3 . 00 

Protein 2 . 40 

Ash 0.50 

One-quarter of the milk and three-quarters water gives: 

Per cent. 

Fat 2.10 

Lactose 2.20 

Protein 1 . 80 

* Prepared by the Widemann Goat Milk Laboratory, San Francisco. 



222 PRACTICAL INFANT FEEDING 

As can be seen from the diluted formulae, the sugar is low, and 
therefore it is well when using this preparation to add sufficient 
carbohydrate in some form to make up for the deficit. 

Beef juice is of value sometimes for babies over eight or 
nine months of age. It has small caloric value, but contains 
about 6 per cent, of protein, and a not inconsiderable amount 
of iron. Its chief purpose is to furnish iron at the time when 
the baby needs more iron than is contained in milk alone (eight 
to nine months). Not more than 2 ounces a day should be 
given, and it is best to begin with only a teaspoonful or two until 
the baby becomes accustomed to it. Bread-cnunbs or rice of 
powdered zwiebach may be added to the beef juice, although 
most babies take it better when given plain. It is best made in 
the following way: 

Lightly broil i pound of lean beef from the top of the round. 
Then squeeze as much juice as possible out of it in a meat press 
(obtainable at most hardware stores), salt, and serve. A half- 
pound of beef usually furnishes about 14 ounces of beef juice. 

CONDENSED MILK AND THE PROPRIETARY FOODS 

Condensed milk has been used extensively in infant feeding, 
but is now being gradually replaced by the dried milks. In 
hot climates, or in any place where fresh cow's milk was not 
available, the use of condensed milk was necessary and advan- 
tageous, but at the present time, when we have good dried milk 
preparations, it should be replaced by them, as they meet the 
nutritive requirements of the infant much more satisfactorily 
than does condensed milk. Condensed milk has also been used 
a good deal in difficult feeding cases, and often recommended by 
authorities on infant feeding, but personally I have had occasion 
to use it only very seldom. It cannot contain anything that 
ordinary milk modifications cannot contain, it is a very poorly 
balanced food, and its chief virtue is its comparative freedom 
from bacteria. It is true that some babies with indigestion 
begin to do well as soon as they are put on condensed milk, but 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 223 

this is probably due more to the weakness of the food than to 
any particular virtue contained in it. 

Condensed milk consists of cow's milk which has been con- 
centrated by evaporation to a small bulk and to which a large 
amount of cane-sugar is added. There are many brands on the 
market the composition of which varies but little. The follow- 
ing figures represent the average composition of twenty well- 
known brands: 

Per cent. 

Fat 8 -10 

Protein 7 -9 

Milk-sugar 11 -13 

Cane-sugar 38 -45 

Ash 1.60-2 

Water 20 -28 

It will thus be seen that condensed milk is a food very low in 
fat, protein, and ash, and very high in carbohydrates. This 
unbalanced composition is its chief defect, as, if it is diluted to 
a point which furnishes a reasonable amount of carbohydrates, 
the protein and salts are diluted so much that the baby is not 
furnished enough of these building materials which are so 
important for proper growth. If it is diluted in such a way that 
the salt and protein percentages are sufficient, the sugar is too 
high. The following table shows the percentages obtained by 
various dilutions of condensed milk: 

Condensed milk. Water. Fat. Sugar. Protein. 

Per cent. Per cent Per cent. 

I Ipart 2 parts 3.00 18 2.00 

II 1 « 4 " 1.80 11 1.60 

III 1 « 6 " 1.00 6 0.90 

It may be of value to carry certaui feeding cases (especially 
those who vomit) along until they can be gradually accustomed 
to a more suitable food, but it is not a food upon which to feed 
any baby over any length of time, and although we see occa- 
sionally a condensed milk baby who has done well, such an 
instance is the exception rather than the rule. In general, 
babies who have been fed condensed milk over a long period of 
time may be divided into three groups: 



224 PRACTICAL INFANT FEEDING 

1. A baby who is of normal weight for his age or grossly 
overweight. He is round and fat and seems well. On closer 
examiQation, however, it is seen that he is pale and his tissues 
are not firm and solid as they should be. He lacks muscle tissue 
and has in its place fat and water. A large part of the gain in 
weight of condensed milk babies is due to water retention, 
caused by the high carbohydrate feeding, as when large amounts 
of sugars are fed over a long period of time, large amounts of 
glycogen are stored in the liver and muscles, and the chemistry 
of glycogen deposition is such that for each molecule of glycogen 
formed 2 molecules of water are retained. These babies gain 
weight quickly, of course; they lose it as quickly, especially 
during any acute infection, which, as a rule, they bear poorly. 
Babies of this type have been supplied enough or more than 
enough calories, but the food has not been well balanced. 

2. A much emaciated baby, usually with rickets, if he is 
over six or seven months of age. This type of baby has been 
fed on a weak dilution of condensed milk over a long period of 
time. His caloric intake has not been sufficient, therefore he 
presents the picture of starvation. He has had just enough to 
keep body and soul together, but not much more. 

3. A baby who is neither very thin nor very fat, but who is 
small for his age. He is delicate looking, rather pale and flabby; 
his hands and feet and bones are small; he may or may not 
have a moderate degree of rickets. This is perhaps the most 
common type of condensed milk baby. 

Evaporated milk is somewhat different from condensed milk; 
it consists of whole cow's milk which has been evaporated to 
the consistency of thin cream and to which no sugar has been 
added. It does not keep in the can as does condensed milk 
(on account of its high sugar content), and a much greater 
quantity of it is necessary to prepare a formula; therefore it 
has not been used nearly so much as condensed milk. The com- 
position of most of the evaporated milks is fat 9 per cent., sugar 
10 per cent., protein 7 per cent. 

One part of evaporated milk to 3 of water gives: Fat, 2.25 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 22$ 

per cent.; sugar, 2.5 per cent.; protein, 1.7 per cent. A 1 :4 
dilution gives: Fat, 1.8 per cent.; sugar, 2 per cent.; protein, 1.4 
per cent. 

It is necessary, in using evaporated milk, to add sugar, as 
the original sugar in the milk is reduced so much by dilution. 

Evaporated milk does not carry with it the same objections 
that were pointed out for condensed milk, but it has been used 
comparatively little in infant feeding, probably on account of 
the reasons given above. 

The Proprietary Foods. — During the early days in the 
development of modern infant feeding, when everyone was 
striving to produce a food which should be the equal of human 
milk, when more attention was paid to the food than to the 
baby himself, and it was thought that it might be possible to 
produce a universal food upon which all babies could thrive, a 
great many proprietary infant foods sprang into being, and 
were extensively used. As interest in infant feeding has in- 
creased, and as practitioners have begun to learn more about 
the modification of milk, the use of the proprietary foods has 
correspondingly decreased. There is nothing in any proprie- 
tary food which cannot be obtained in any ordinary milk 
mixture prepared with the ordinary materials used (various 
sugars, starches, dextrins, creams, etc.), and it is a great deal 
better for the practitioner to prescribe his own mixture than to 
use bhndly one which is furnished him in a can. There is 
nothing fraudulent in their preparation, and, in general, their 
composition corresponds closely to the analyses given on the 
package. The chief objection to them is that their claims are 
exaggerated, that their use tends to develop sHpshod methods 
of feeding, and that most of them do not contain the food 
elements in suitable ratio for the proper nutrition of the baby. 
They are still used by the laity to a considerable extent, and 
all of us have occasionally seen strong, healthy babies raised in 
this way, but we have seen far more who have not done well 
after having been shifted from one proprietary food to another. 

Some of the proprietary foods consist entirely of starch, 

IS 



226 



PRACTICAL INFANT FEEDING 
TABLE I 



Food. 



A. D. S. Malted Milk 

Allenbury's Milk Food No. 1 . 
AUenbury's Milk Food No. 2 . 
Allenbury's Milk Food No. 3 . 

Benger's Food 

Borden's Malted Milk 

Carnrick's Lacto-Preparata. . . 

Camrick's Soluble Food 

Cereal Milk 

Eskay's Albuminized Food . . . 

Horlick's Malted Milk 

Imperial Granum 

Just Food 

Lacnut 

Lactated Food 

Meadow Brand Malted Milk . 

Mellazea 

Mellin's Food 

Nestle 's Food 

Peptogenic Milk Powder 

Ridge's Food 

Wampole's Milk Food 

Dennos Food^ 

Laibose^ 

Mammala" 

Kindolac- 

Trumilk- 



Fat. 



6.75 
13.80 
14.20 
0.78 
0.83 
7.15 
1.60 
1.05 
3.55 
1.28 
8.10 
0.50 
0.03 
31.30 
0.55 
5.20 
2.20 
1.801 
5.70 
0.03 
0.33 
5.25 

1.17 
15.83 
12.12 
12.93 
28.73 



Soluble 
carbo- 
hydrate 
sugar. 



66.97 
62.80 
66.40 
17.54 

9.69 
65.30 
74.80 
53.45 
71.95 
49.19 
66.04 

2.00 
90.30 
36.08 
29.87 
68.09 

1.62 
75.27 
55.48 
90.89 

3.12 
65.14 

16.64 
54.05 
55.34 
60.78 
35.20 



Starch. 



None 
None 
None 
60.92 
57.66 
None 
None 
25.99 
1.74 
31.95 
None 
72.79 
3.32 
2.31 
47.93 
None 
74.36 
None 
20.25 
None 
70.93 
None 

57.0 
None 

None 
None 
None 



Protein. 



14.06 

9.88 

9.75 

9.38 

10.75 

15.38 

13.63 

12.44 

11.00 

7.75 

15.00 

13.88 

0.63 

22.19 

8.81 

14.50 

5.75 

11.31 

11.94 

0.19 

10.31 

9.19 

11.10 
19.8 

24.35 

19.9 

26.52 



Ash. 



3.08 
3.98 
3.70 
1.18 
1.00 
3.45 
3.38 
1.30 
2.38 
1.58 
4.00 
0.50 
0.30 
2.10 
0.88 
3.28 
0.60 
4.45 
1.45 
1.43 
0.75 
4.83 

0.79 
5.30 
4.93 
4.39 
5.47 



dextrins, and malt sugar, and are intended to be mixed with 
fresh milk; some contain these substances in combination with 
dried milk, and are advertised as complete foods; some contain 
sugar or starches in combination with digestive ferments. If 
better results in infant feeding could be obtained by the use of 
proprietary foods than in any other way we should all use them 

1 Is 0. 16 per cent, according to other analyses. 

2 Analyses furnished by Mellin's Food Co. 



SPECIAL PREPARATIONS USED IN INFANT FEEDING 



227 



TABLE II 

Percentage Composition of Feeding Mixtures, Prepared According 
TO Directions, for Infants Three Months Old 



Food. 



A. D. S. Malted Milk 

Allenbury's Milk Food No. 1 
Allenbury's Milk Food No. 2 

Benger's Food 

Borden's Malted Milk 

Carnrick's Lacto-preparata . . 

Carnrick's Soluble Food 

Cereal Milk 

Eskay's Albuminized Food . . 

Horlick's Malted Milk 

Imperial Granum 

Just Food 

Lactated Food 

Meadow Malted Milk 

Mellazea 

Mellin's Food 

Nestle's Food. . , 

Peptogenic Milk Powder . . . . 

Ridge's Food 

Wampole's Milk Food 



Fat. 


Carbo- 
hydrate. 


Protein. 


0.81 


8.46 


1.69 


2.17 


10.61 


1.56 


2.24 


10.73 


1.53 


1.75 


4.14 


2.10 


0.88 


8.44 


1.88 


0.07 


3.55 


0.62 


0.10 


8.00 


1.19 


0.49 


10.69 


1.51 


1.77 


4.77 


2.16 


1.08 


9.42 


1.99 


1.78 


3.58 


2.10 


2.47 


6.65 


2.63 


1.86 


3.73 


2.11 


0.66 


9.34 


1.83 


3.40 


7.00 


2.05 


1.93 


5.55 


2.42 


0.36 


4.84 


0.75 


2.04 


5.01 


1.66 


1.75 


4.06 


2.09 


1.02 


15.30 


1.78 



Ash. 



0.34 
0.63 
0.58 
0.36 
0.42 
0.15 
0.13 
0.33 
0.40 
0.53 
0.35 
0.49 
0.38 
0.42 
0.32 
0.38 
0.09 
0.34 
0.36 
0.93 



exclusively. Such is not the case. Table I, taken from Part V 
of the annual report for 1915 of the Connecticut Agricultural 
Experiment Station, shows the analyses of most of the proprietary 
foods. Table II, taken from the same source, shows the com- 
position of the feeding mixtures prepared from certain of these 
foods, according to the directions furnished, for infants three 
months old. 



CHAPTER IX 
THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 

NoEMAL babies may thrive on foods of widely different 
compositions, as they have to a considerable extent the power 
of adapting themselves to varying diets. So it may be said that 
there is no one and only correct way to feed a baby; any milk 
modification upon which he will thrive is a satisfactory feeding 
for him. The type of food, however, which suits most babies is 
naturally the best one for general use. Although it is undoubt- 
edly true that individualization and the fitting of the food to 
the infant are extremely important points to bear in mind, it is 
also true that most normal babies do well when fed by very 
much the same plan of feeding. Although we do not try now- 
adays to imitate breast milk, it is not unreasonable to suppose 
that babies should do well on a food of the same general char- 
acter as breast milk, that is, relatively high in fat and sugar, 
and low in protein and salts. A food of this nature can best be 
obtained by the use of gravity cream and skimmed milk mixtures. 
There has been a great deal of discussion among pediatrists as 
to whether babies do better on high fats and low proteins or 
low fats and high proteins. My own feeling is that they do better 
on the former, and I therefore use this method of feeding more 
than any other, although not exclusively. High fat is usually 
well borne if the protein is kept low; high fat plus high pro- 
tein or high sugar plus high protein is not tolerated. As a 
matter of fact, there is no need for a baby to take a large amount 
of protein; we know that breast milk contains only a Httle over 
1 per cent., and still, with an adequate amount of fat and sugar 
to serve as fuel, this enables the baby to keep in nitrogenous 
equihbrium, and to retain a considerable amount of nitrogen. 
Normal bottle-fed babies, likewise, do very well on a relatively 
low protein food provided enough fat and sugar is supplied for 
228 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 229 

the fuel needs of the body, so that little or none of the protein 
has to be used for this purpose. 

In using a high fat, cream is essential, and it is, therefore, 
always necessary to speak and think in terms of percentages of 
the food elements in employing this method. With several 
ingredients in the mixture, such as cream, skimmed milk, and 
sugar, we are hopelessly confused unless we adhere strictly to 
the percentage method of expression. Note that I say * 'expres- 
sion" and not "system," for percentage feeding is not a system, 
it is a method of expression merely, which becomes necessary 
if one is to have an adequate idea of what he is doing, particu- 
larly if he uses cream or cream and skimmed milk mixtures. 
Expression in percentages is intended to serve merely as a gen- 
eral guide, and it is by no means necessary to make the very 
sHght changes in percentage or to strive for the meticulous 
accuracy that was insisted upon by the early advocates of 
percentage feeding. Various percentages, such as 1, 1.50^ or 2, 
represent merely different gradations of concentration of a food 
element in a formula, and it is not supposed that a chemical 
analysis would show the exact percentages called for. This is 
no disadvantage, however, as what is desired is not absolute 
but relative accuracy, in order to express approximately the 
concentration of the food elements, and to indicate how much 
we have raised or lowered the amount of any element in a 
mixture. If these suggestions are borne in mind the percentage 
method of expression will be found to be a real help. 

The composition of the food, that is, the relationship of the 
fat, sugar, and protein to each other, is the first point to decide 
in feeding any given case; the caloric value of the daily ration 
can be increased or diminished by changing the amount at each 
feeding or the number of feedings. 

In the "caloric method" of feeding, so called, the total 
niunber of calories necessary per day is first determined, and 
the mixture is made up in such a way as to furnish the required 
calories, allowing a certain number for each ounce of whole 
milk, cream, or sugar used. There are several objections to 



230 PRACTICAL INFANT FEEDING 

this way of feeding. In the first place, the caloric needs of 
different babies vary so much that the fact of supplying a 
theoretically correct number of calories in the mixture is no 
criterion whatever that the baby will gain. Second, the caloric 
method does not take into close enough account the composi- 
tion of the food, and it is possible to secure an equal number 
of calories from mixtures which are widely different in their 
composition, and which might or might not be suitable for the 
baby. The following three formulae contain the same nimiber 
of calories; Mixture No. 1 would be a suitable feeding for a 
baby of three or four months. Mixtures No.s 2 and 3 would be 
utterly unsuitable. 

Fat. Sugar. Protein. 

Per cent. Per cent. Per cent. 

No. 1 3 6 1.50 

No. 2 5 2 1.50 

No. 3 11 2.50 

(Ladd.) 

It is often useful, however, to calculate the calories in the 
daily feeding after its composition has been determined, and 
such calculation is often valuable as a check, if one is not quite 
certain whether or not he is covering the theoretic caloric needs 
(see Chapter VI). 

General Plan of Feeding. — The artificial feeding of the 
normal baby during the first year may be divided into three 
stages: 

1. From birth to the end of about the third week: In this 
stage a very weak food is used at first, in very small amounts, 
which is rapidly increased until a permanent formula, upon 
which the baby can gain weight, is reached. This newborn 
period I like to speak of as the * 'stage of establishing the food 
tolerance." 

2. From the third or fourth week up to the eighth or ninth 
month: This is the stage when the baby gains most of his 
weight. There are relatively few changes made in the formula 
during this period, the most important being the gradual raising 
of the protein. 



TEE ARTIFICIAL FEEDING OF THE NORMAL INFANT 23 1 

3. From the eighth or ninth month to the end of the first 
year: During this period a change is made from gravity cream 
and skimmed milk mixtures to concentrated whole milk dilu- 
tions, which are gradually increased until whole milk is reached 
at about the end of the first year. Other foods besides milk are 
also added at the beginning of this period. 

The Newborn Period. — Nev/bom babies are not easy to feed 
artificially; they do not gain weight so rapidly or so regularly as 
breast-fed babies, and are very prone to digestive upsets. Fur- 
thermore, once a newborn baby has developed a digestive upset, it 
is often exceedingly difficult to correct it. The principal thing to 
remember is to start with a very weak food in small amounts, and 
to strengthen it at frequent intervals, until the baby is on a food 
which will cause him to gain weight. A newborn baby should 
always be imderfed for the first week. It must be remembered, 
however, that his tolerance for food increases rapidly, and he 
must not be kept too long on a weak food. For the first twelve 
hours the newborn baby should be given nothing but water. A 
solution of lactose or of cane-sugar is often given, with no good 
reason. Nature intended that a baby should have no food for 
the first few hours, and if a sugar solution is given it is possible 
to initiate undesirable fermentation in the intestines and to 
interfere with the normal development of the intestinal flora. 
This has been especially emphasized by Czemy. 

Table I shows in a general way what most newborns would 

be fed: 

TABLE I 

First Nutritional Period (One to Three Weeks) 

Age, Fat. Sugar. Protein. Amount, Interval, Number of 

davs. ounces. hours. ; feedings. 

1 1.50 5 1.00 I 2 10 

2 1.50 5 1.00 U 2 10 
5 2.00 6 1.00 2| 2| 8 

10 2.50 6 1.00 3 2i 8 

21 3.00 6-7 1.25 3i 2* 8 

By this time, in most cases, the baby will have regained his 
birth weight, and should be gaining regularly. The last strength 



232 PEACTICAL INFANT FEEDING 

of formula suffices most babies for a considerable period, and if 
a sufficient gain does not result, it is better to increase the 
amount at each feeding rather than the strength of formula. 
Newborns will ahnost always do better on a boiled formula than 
on a raw, therefore for the first three weeks, at any rate, the 
formula should be boiled vigorously for from three to five 
minutes. 

Second Period: Three Weeks to Nine Months.— It is in this 
period that the baby does most of his growing. At the begin- 
ning of this period the night feedmg should be omitted, and 
the last feeding given at 9 or 10 p. m. It is well, when breaking 
off the night feedmg, to give an extra ounce at the 10 p. m. 
feeding, and this extra amount may be enough to carry the 
baby through the night without difficulty. It is desirable, if 
possible, to have the night feeding omitted before the obstetric 
nurse leaves, as in this way the mother is saved considerable 
trouble. 

Table II shows in a general way how the food would be 
increased from the first to the ninth month. It must be dis- 
tinctly borne in mind, however, that no tables can cover all 
cases, and that wide variations may be necessary for individual 
babies. 

TABLE II 
The "Growing" Period: Three Weeks to Nine Months 

Starch. Amount, Interval, Number of 



0.75 
0.75 



It is not advisable to change the formula often; if the baby 
is gaining weight, it is much better to leave it alone. Care 
must be taken, however, that the mother reports regularly at 
stated intervals, so that the food may be increased if necessary. 



Age. 


Fat. 


Sugar. 


Protein. 


months. 








1 


3.00 


6-7 


1.25 


2 


3.00 


7 


1.25 


4 


3.00 


7 


1.50 


6 


/3.OOI 
1 3.50f 


7 


1.75 


8 to 9 


/3.O0I 
\3.5Oj 


7 


e:Sl 



ounces. 


hours. 


feedings. 


4 


21 


7 


4^ 


21 


7 


6 


3 


6 


7 


3 


6 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 233 

It will be noted that in this period the chief change in the com- 
position of the food is the gradual increase in the protein (and 
hence calcium) to allow for the growth needs. 

The Third Period: Nine Months to One Year.— At this 
time the gravity cream and skimmed milk mixtures are dis- 
continued, and whole milk dilutions are substituted. The 
usual formula at nine months would be 

Whole milk 36 ounces 

Barley-water 12 ounces 

Lactose 4 level tablespoonf uls 

Six feedings of 8 ounces each. 

The percentage composition of this formula equals fat 3, 
sugar 6.50, protein 2.40, starch 0.50. From now on it is not 
necessary to express the formula in percentages, and the 
amount of barley-water is gradually reduced and the milk 
increased, until whole milk undiluted is reached at about eleven 
or twelve months. If the mixture is boiled some babies can take 
it before this. When whole milk is reached the sugar is omitted. 

Feeding with Whole Milk Mixtures from the Start. — If it is 
desired to use whole milk mixtures from the beginning, instead 
of gravity cream and skimmed milk formulas as described above, 
the feeding would proceed somewhat in accordance with the 
table below, the amount at each feeding and the interval between 
feedings being about the same as with the other method. In 
using whole milk dilutions a high concentration of milk is given 
at a comparatively early age, and for this reason it is well, 
when feeding a baby by this method, to boil the mixture in 
order to render the casein curd more digestible. It is possible 
to feed a good many normal babies successfully in this way, 
but, as has been said before in another chapter, it has its dis- 
advantages. 

Percentages, 
Age. Milk. Water. Added sugar. Fat. Sugar. Protein. 

2 days | | Up to 5 per cent. 1.30 5.00 1.1 

4 to 6 weeks ^ | Up to 7 per cent. 2.00 7.00 1.60 

4 months f ^ Up to 7 per cent. 2 . 60 7 . 00 2 . 20 

7 months f i Up to 7 per cent. 3 . 00 7. 00 2.40 

lOto 11 months Whole None 4.00 4.50 3.20 



234 PRACTICAL INFANT FEEDING 

It must be again repeated that any tables give only a gen- 
eral idea of what is suitable for the average baby, and in many 
individual cases the proportions given in the tables might not be 
at all suitable. 

Solid Food. — ^At the eighth or ninth month it is well to 
begin cereal, fed from a spoon, partly to furnish additional 
nourishment and partly to teach the baby how to eat. A great 
deal of trouble is often experienced in teaching babies to eat 
semisolid or solid food. If spoon feeding is begun early, this 
trouble is minimized. Farina, strained oatmeal, or barley 
jelly can be used as the cereal, and most babies at nine months 
can take 2 or 3 tablespoonfuls a day without any trouble. Three 
or 4 ounces of a meat soup with a little rice in it may also be 
given at about this time on a small piece of zwieback softened 
with milk. Beef juice may also be begun at nine months, and 
can be alternated with the soup. Not more than 2 ounces a day 
should be given. 

Green Vegetables. — I sometimes have carrots or spinach 
cooked in the soup, and then removed by straining, before the 
soup is given to the baby. In this way he gets a considerable 
amount of the iron content of the vegetables without the irritating 
and indigestible cellulose. I do not beHeve in the practice of feed- 
ing green vegetables or potato to young babies, and can see no 
good reason for it, although it is done by a good many well-known 
pediatrists. The practice originated in Germany, probably with 
Heubner, who, on account of the lack of iron in cow's milk, in 
1895, at the Congress of Internal Medicine in Munich, advised 
giving a teaspoonful of spinach a day to babies of nine or ten 
months. Czerny likewise advised it, and laid especial stress on 
using not more than a teaspoonful or two, having it very finely 
ground, and not beginning to use it until nine or ten months. 
In this country, in recent years, the practice of giving vegetables 
to small babies has been pushed to an extreme, and we often 
see babies of seven or eight months who are taking large amounts 
of potato and other vegetables. It is undoubtedly true that 
some babies have such strong digestions and tough digestive 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 23$ 

tracts that they can stand this sort of feeding, but many babies 
will develop severe chronic intestinal indigestion if given large 
amounts of vegetables, especially potato, at too early an age. 
There is no harm in giving small amounts of spinach puree to 
small babies as a definite therapeutic measure in anemia, but 
in my opinion there is absolutely no excuse or rationale for 
potato, squash, turnip, carrots, string beans, etc. There can 
be only two reasons for the procedure brought forward by its 
exponents: 

1. That the vegetables supply vitamins which will reduce the 
danger of scurvy and possibly of rickets. 

2. That they supply ''salts," and that the baby needs more 
"salts" than are supplied him by farinaceous food and milk. 

1. As far as scurvy is concerned, there is no better anti- 
scorbutic than orange juice. If the baby is fed on fresh raw 
milk he does not need even this. If he is fed on a cooked milk 
he does need it, and usually takes it well, without running the 
risk of digestive disturbance that the vegetable feeding carries 
with it. Raw orange juice, moreover, is a much more powerful 
antiscorbutic than are either raw or cooked vegetables. 

As regards rickets, small babies fed carefully on suitable 
milk modifications with the addition of cereal, soup, and possi- 
bly beef juice after the age of eight months, do not develop it. 
There is no good proof that rickets is caused by lack of vitamins 
or that green vegetables will prevent it. Furthermore, cow's 
milk contains an abundant supply of both the fat-soluble ''A" 
and water-soluble ''B" vitamins. These are much more stable 
than the antiscorbutic vitamins, and it has been shown that 
they are little if any affected by heating of the milk. Thus 
we see, that as far as vitamins are concerned, the baby may be 
amply supplied with them without the use of green vegetables. 
In the treatment of already developed rickets, green vegetables 
possibly have some value, in just what way is not clear; as a 
prophylactic they are not necessary. 

2. As regards salts, cow's milk is so rich in this respect, 
with the exception of iron, of which it contains only traces, that 



236 PRACTICAL INFANT FEEDING 

there can be no question of the baby's receiving an insufficient 
supply of salts, mth this possible exception. We come, then, to 
the only real reason for feeding green vegetables to young babies; 
that is, the small iron content of cow's milk. It is a clinical fact 
that well-cared for bottle-fed babies do well and do not get 
anemic during the first seven or eight months with milk as their 
only food. This is evidence that the small amount of iron in 
cow's milk plus the reserve supply contained in the liver is suf- 
ficient to cover their iron needs during this period. It is also a 
cHnical fact that babies who are kept on an exclusive milk diet 
after the eighth or ninth month soon become anemic and flabby 
and do poorly. This is presumptive evidence that cow's milk 
does not contain enough iron to supply the iron needs after this 
period, and that additional iron-containing food of some sort 
should be added. What foods shall be used? Is it possible to 
cover the iron needs with cereals and beef juice, or must we turn 
to vegetables? There are no figures available which indicate 
the iron needs of babies. Cow's milk contains about 0.6 milli- 
gram of iron to the liter, human milk, about 1.6 milligrams. 
Even breast milk, therefore, contains only a very small amount, 
and the iron needs of a baby must be very small. Morse^ has 
calculated, using the adult iron needs for a standard, that a 
Hberal estimate of the iron needs of a baby of 25 pounds is 
0.0025 gm. daily. This is about one and one-half times the 
amount of iron contained in a liter of breast milk, and would seem 
to be a not unreasonable estimate. Is it possible to supply this 
amount of iron by means of milk, cereal, and beef juice? 

Iron, gm, 
1 liter of cow's milk contains 0. 0006 

1 ounce of beef juice contains 0. 0019^ 

3 tablespoonf uls of cooked cereal contain . 0009^ 

0.0034 

These figures show that it is possible to considerably in- 
crease the amount of iron in the diet without the use of vege- 
tables, and clinically it is a fact that babies fed in this way up 
1 Jour. Amer. Med. Assoc, vol. 74, 1920. 2 Hjjd. 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 237 

to the thirteenth or fourteenth month do not become anemic, 
and do well. If vegetables are given, spinach is the only one 
which has any excuse for being used, as it is the only vegetable 
which contains enough iron to amount to anything, and a few 
teaspoonfuls of well-strained spinach daily in the form of a 
puree should do no harm after the ninth month, but in most 
cases it is not necessary. 

Amount at Each Feeding. — Babies vary a great deal in the 
amounts which they need at each feeding in order to be satis- 
fied. A baby would naturally take more at each feeding if fed 
every three hours than he would if fed every 2 J hours, and the 
twenty-four-hour amount of milk must always be borne in mind 
if the intervals between feedings are to be changed. In general, 
in the first few weeks the amount given at each feeding has to 
be increased very rapidly, then more slowly. It is not possible 
to say exactly how much any baby, particularly a young one, 
needs; and if he is not satisfied with his feeding, the amount of 
the feeding should be increased J ounce at a time until he is 
satisfied. Spitting up is the first sign that he is getting too much, 
and if he does this, drop back to a smaller amount at each feed- 
ing, and later increase the strength of the food. As regards 
amount, pediatricians in general are rather prone to give too 
little. I am accustomed to give my mothers a good deal of 
latitude in this respect, and within certain limits to allow them 
to regulate the amount at each feeding themselves. A baby of 
two months should not take more than 5 ounces, a baby of four 
months more than 6 ounces, or one of six months more than 8. 
Babies of nine or ten months often wiU take 9 or 10 ounces, par- 
ticularly if fed at four-hour intervals, but should never be 
allowed to take more than this. The size of the stomach at 
different ages is no guide whatever to the amount that can be 
taken at each feeding, for a considerable amount of the first part 
of the feeding leaves the stomach before the last part enters it. 
No baby should take more than 48 ounces in total quantity per 
day, and if he is not satisfied with this it is time to begin to give 
him soHd food. 



238 PRACTICAL INFANT FEEDING 

Interval. — For babies in the first three weeks of life small 
amounts of food at frequent intervals (2 to 2| hours) seem to 
work best; after this period the three-hour feeding will usually 
be most satisfactory. If it is desired to get a little extra food 
into a baby who will not take large amounts at one time, babies 
of four or five months may often be fed with advantage every 
2| hours. The four-hour interval I do not believe in for most 
bottle-fed babies, as in order to get enough in total food value 
with such infrequent feedings it is necessary to feed them large 
amounts of a very concentrated food. In the case of unusually 
large, robust babies, however, this carries with it no objection. 

Amounts of the Food Elements to Use. — Fat. — ^The usual 
dictum is, not to feed more than 4 per cent, of fat to any baby. 
I rarely use more than 3, and never as much as 4; 3 per cent, is 
enough for the vast majority of babies, and one runs much less 
risk of a fat upset than if more is used. If more fat is given 
the protein must be kept low, for high fats and proteins do not 
go well together. Two of the first symptoms of overfeeding 
with fat are loss of appetite and spitting up. It is not at all 
uncommon to see babies being fed on a cream dilution containing 
5 or 6 per cent, of fat, when the physician in charge has simply 
given directions for diluting the "top of the bottle," and has 
not figured the fat percentage of his mixture. In using any 
cream or cream and skimmed mixture it is always necessary to 
know the percentage of fat in the original cream used and in the 
resulting mixture. 

Sugar, — ^Most of the books say never to use over 7 per cent, 
of sugar. This is, in the main, a good working rule, but may 
often be advantageously broken. There are many babies, 
normal and abnormal, who are not gaining well on 7 per cent, 
of sugar, and who need just a little more carbohydrate for fuel. 
As much as 8 or 9 per cent, may be given to these babies without 
harm, and with considerable increase in weight and well being, 
provided the fat and protein in the mixture are not too high. 
If a baby's stools are alkaline in reaction, and smooth and 
formed, it is practically always safe to give him more sugar. If 



I 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 239 

they have a tendency toward looseness and are acid, be careful 
of it. In feeding high sugars it is best to use a combination of 
sugars, such as lactose and dextrimaltose, rather than one sugar 
alone. 

Starch. — ^Although it has been shown many times that starch 
can be digested to a certain extent by newborn babies, it is not 
ordinarily given until the sixth or seventh month, although in 
special cases, where the sugar tolerance is low, and it is desirable 
to increase the food with some less easily fermentable carbo- 
hydrate, it may be used much earlier than this. The usual 
amount employed is about 0.75 per cent. With most normal 
babies, however, there is no particular reason for starting starch 
before the eighth or ninth month. 

Protein. — In most of the ordinary milk mixtures a baby 
receives an adequate supply of protein, and if enough fat and 
carbohydrate is given to supply his fuel needs, there is little 
danger of underfeeding in this respect. A one-third dilution of 
the protein of cow's milk gives about 1.20 per cent, of protein, 
which is all there is in breast milk, and I have seen a few babies 
do well on this amount up to the sixth or seventh month. In 
general, however, it is better after the third month to begin 
to increase the protein, and most babies at eight months would 
be taking 2 or 2§ per cent. It must be remembered that when- 
ever we increase the concentration of the milk in order to increase 
the protein we increase the salts as well. A small baby who could 
take perhaps 3 per cent, of fat and 1.50 per cent, of protein with- 
out trouble, gets into difficulty as soon as the protein is raised 
to 2.50 per cent., whereas he might be able to take the high 
protein perfectly well if it were not for the high fat. It is very 
probable that it is not the protein alone which causes this trouble, 
but also the increase of calcium which goes with any increase of 
protein. 

Alkalies.— It is not usually necessary to add an alkali to 
the food of the average normal baby, unless he is being fed on an 
unusually high protein percentage, in which case sodium citrate 
or lime-water may be used, in accordance with the directions 



240 PRACTICAL INFANT FEEDING 

given in Chapter IX. Some quite normal babies, however, as 
soon as the protein in their food gets up to 2 or 2.50 per cent., 
will show casein curds in the stools. In these cases it is well to 
use an alkali or to boil the milk. 

Gain in Weight. — There are fat normal babies and lean normal 
babies, as there are fat and lean normal adults, and the fact that 
a baby is slightly below the average weight for his age does not 
necessarily mean that he is not doing well, provided his flesh is 
firm and pink, and that he is doing well in other ways. Con- 
versely, a very fat baby is not necessarily healthy, and, as a 
matter of fact, excessive fat is no more desirable in a baby than 
in an adult. There are babies who grow very fat on a com- 
paratively small amount of food, and others who are always 
perfectly healthy, but never very fat, no matter what they are 
fed on. There are so many variations in the individual that 
averages are likely to be somewhat misleading, but the average 
baby will double his birth weight at five months, and treble it 
in a year. A good many carefully fed babies in private practice 
will do considerably better than this. 

The following table from Griffith^ shows the average weights 
of normal breast-fed babies at different ages : 

Age. Weight. Age, Weight, 

months. pounds. 



At birth 


7 lbs. 


8 


oz. 


5 


15 


1 week 


7 lbs. 


n 


oz. 


6 


m 


2 weeks 


7 lbs. 


lOi 


oz. 


7 


m 


3 weeks 


8 lbs. 


2 


oz. 


8 


m 


1 month 


8f lbs. 






9 


181 


2 months 


lOf lbs. 






10 


191 


3 months 


m lbs. 






11 


201 


4 months 


m lbs. 






12 


211 



Daily weighing for the first three weeks is desirable; after 
this it is not well to weigh more than once a week, as a slight loss 
or no gain may upset the mother too much. With a normal 
baby during the first few months gains in weight of from 5 to 
8 ounces should be registered each week; after this the weekly 
1 Diseases of Infants and Children, W. B. Saunders Co., 1919. 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 241 

gain is not so great. No baby gains the same each week, and 
often a normal baby may do only 2 or 3 ounces one week, and 
make it up by a large gain the next. Small gain for one week 
does not necessarily indicate that the baby is doing poorly; 
small gain for longer than this indicates that something is 
wrong. Either the baby is bemg underfed, is having indigestion 
of some sort, or is not gaining on account of poor appetite 
possibly caused by beginning rickets, teething, or a cold in the 
head. If a normal baby gains steadily more than 8 or 9 ounces 
a week it is usually best to reduce the food somewhat, as this is 
an indication that it is being pushed nearly to the limit, and 
indigestion may soon develop. 

Weights of Older Children. — The table below^ shows the 
average weights in children from one to five years of age. 
These are somewhat below the figures that may be expected 
for robust children of the upper classes in private practice. 

Age. Weight, pounds. 

Twelve months 22 . 1 

Thirteen months 22 . 5 

Fourteen months 23 . 3 

Fifteen months 23 . 9 

Seventeen months 25.2 

Eighteen months 25 . 3 

Nineteen months 26. 1 

Twenty months 26.5 

Twenty-one months 26 . 3 

Twenty-two months 26.8 

Twenty-three months 27 . 5 

Two years 28 . 

Three years 32 . 9 

Four years 36. 1 

Five years 41.2 

There has in the last few years been a nation-wide move- 
ment to weigh and measure all children in order to detect mal- 
nutrition, which, in the main, is commendable, but there has 
been altogether too much tendency to feel that a child must 
conform to the theoretic weight requirements in order to be 

* Griffith, quoted from Camerer. 
16 



242 PRACTICAL INFANT FEEDING 

considered in satisfactory condition. This is by no means so; 
many perfectly healthy children are naturally thin. Also the 
children of small parents, those who have small frames, small 
hands and feet, are likely to weigh somewhat less than the 
children of large parents, and a great deal of unnecessary worry 
is caused a mother on account of the fact that her baby does 
not weight as much as her neighbor's naturally larger child. 

Stools. — The stools of a normal artificially fed baby vary 
according to what t3^e of mixture he is fed on, but in general 
are from one to three a day in number, rather pasty and formed 
in a good many cases, and sKghtly foul smeUing. Mothers 
worry a good deal about constipation, but a shght tendency 
toward constipation should always be a welcome sign to the 
doctor. A Httle constipation is of absolutely no harm to a 
baby, provided it is not enough to make him uncomfortable. 
Many text-books and mother's manuals are explicit in laying 
down the rule that a baby must have at least one movement 
every twenty-four hours, and this statement has caused a great 
deal of worry to young mothers and trouble to doctors. It is 
natural for a bottle-fed baby to be a Kttle constipated, and a 
mild constipation does him more good than harm. There are 
many well babies who often skip a day without having a move- 
ment, and provided it does not give them gas and colic, there is 
no necessity of doing anything about it. No baby should be 
allowed to go for forty-eight hours without a movement, how- 
ever, and the best way of bringing this about is by a simple 
soapsuds enema or a teaspoonful of milk of magnesia. Sup- 
positories are not good for continued use, and I have only 
recently seen a bad case of proctitis brought about in this way. 
If the constipation becomes more than is normal, a decrease in 
the protein of the food, and an addition of a couple of table- 
spoons of Malt Soup Extract to the total daily feeding wiU 
often correct it. If the constipation be excessive, or if it is due 
to the formation of white * 'soapy stools," it is pathologic, and 
will be discussed under the proper headings. 

There is no normal baby who does not occasionally, espe- 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 243 

daily during periods of warm weather, have an occasional loose 
stool. If the strength of the food is immediately reduced for 
three or four feedings this is usually the end of the trouble, and 
often a serious fermentative diarrhea may be avoided if this is 
always done immediately on the appearance of such a stool. 
Usually diluting whatever formula the baby is taking one-half 
with water is sufficient. 

The Urine. — Many normal babies fed on high proteins are 
very likely to have a very ammoniacal urine. This is of a 
different type from the ammoniacal urine seen in cases of fat 
indigestion, and usually is cleared up by reducing the amount 
of protein in the food and increasing the carbohydrate. 

Water. — If babies under a year old like water, they may have 
it; if not, it is not necessary to force it upon them, as they get 
a great sufficiency of water for all their metabolic needs in the 
comparatively large amount of milk they take each day. If an 
adult weighing 150 pounds took as much fluid in proportion to 
his body weight as is taken by a 15 -pound baby in a quart of 
milk a day he would take about 9 quarts. If a mother who calls 
up and says ^^My baby won't take water, what shall I do?" is 
simply told this ratio, her fears are at once forever quieted. 

Orange Juice. — ^A tablespoon or two of orange jxiice is ordi- 
narily added to the diet at about the third month. This is 
necessary if the baby is taking a boiled or a pasteurized milk. 
It is not a necessary part of the diet if raw milk is used. Orange 
juice is commonly supposed to be laxative, but, as a matter of 
fact, it has but Kttle laxative action in most babies. In a few 
cases it acts as a most efficient laxative, however. 

Orange juice should be given about an hour before the 
feeding. It can be diluted with water, or may have a Kttle 
cane-sugar added to it if the baby prefers it this way. If it 
causes * 'spitting up," sometimes the addition of a small amount 
of lime-water will prevent this. 

Spitting Up. — ^A great many normal babies spit up a mouthful 
or two after some of their feedings. This may mean that the 
total quantity ingested is too great, or it is very likely to mean 



244 PRACTICAL INFANT FEEDING 

nothing whatever, and if the baby is doing well, having good 
stools, and gaining weight, it is not necessary to pay any atten- 
tion to it. Babies fed on a malt sugar preparation are the ones 
most likely to do it. 

Gas. — Every normal baby has a little gas occasionally, and 
passes it either by mouth or rectum, or retains it, in which case 
he has colic. The best treatment for discomfort from gas is: 

1. Holding on the shoulder, and patting the baby's back in 
order to force the gas from the stomach. 

2. A soda-mint tablet, dissolved in a tablespoonful of warm 
water. 

3. A soapsuds enema. 

Crying. — Every baby, normal or abnormal, cries con- 
siderably. It is the only way he has of expressing himself; it is 
his most important mode of exercise. Normal babies vary 
greatly in the amounts of crying they do, some are naturally 
"good," while a few, although perfectly healthy, cry a good part 
of the time, and make life miserable for the mother or nurse. 
A large part of this trouble is caused by faulty training, and it is 
often difficult to make the mother understand that there is 
nothing the matter with the baby when he is probably merely 
crying from temper or because he is lonesome. If a crying baby 
is doing well as regards his feeding, is not sick, and stops crying 
the minute he is picked up, he can safely be left to "cry it out," 
and should be so left. It will do him no harm, and in my 
opinion one of the most important duties of the obstetric nurse 
is to have the baby well started on the right training before she 
leaves the house. The time to start is as soon as the cord is 
tied. 

General Condition. — A well baby, whose nutrition is pro- 
gressing satisfactorily, has a pink skin and firm flesh. The 
"tissue turgor," so called, or the firmness of the flesh, is one of 
the most important indications of the satisfactory state of his 
nutrition. I always Hke particularly to look at the legs and 
buttocks of babies to determine the firmness of the flesh, and 
well-rounded, firm, pink buttocks usually mean a good state of 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 245 

nutrition. Very little can be told from the face; many babies 
whose flesh is soft and flabby may have roimd, fat faces. 
Furthermore, many apparently fat babies, who weigh more 
than the average for their ages, may be, in reaHty, in a very 
poor state of nutrition, which is evidenced by their pallor and 
the flabby condition of their flesh. Babies fed on condensed 
milk or on very high carbohydrate diets containing too small an 
amount of protein are very likely to be of this type, and the 
excess weight is due, in reality, to water retention brought 
about by prolonged overfeeding with carbohydrate. These 
babies bear illness very poorly, and lose weight rapidly during 
any infection or acute digestive disturbance. 

Babies vary a great deal in the amount of "color" they show 
in their faces. It is the ambition of every mother to have a 
baby with rosy red cheeks, and, of course, a great many well- 
fed, robust babies are of this type, but others equally healthy, 
of the same weight, and with the same tissue turgor, may have 
color only occasionally, and may look rather pale at other 
times. This does not necessarily mean that there is anything 
wrong with the baby; it probably has something to do with the 
state of the vasomotor system and the texture of the skin, and 
also probably a good deal to do with heredity. Many people 
naturally have little "color," and babies are likely to resemble 
their parents in this respect. 

A great many babies begiu to cut teeth at six or seven months, 
but many normal babies will not begin until a month or two 
later than this. One should always think of a mild rickets in 
connection with late dentition, but evidences of this are by no 
means always found, and I have seen one perfectly normal, 
well-developed baby without the slightest sign of rickets, who 
never cut a tooth imtil she was fourteen months old. One 
pediatrician of experience has said that all bottie-fed babies 
have a littie rickets, and it is certainly true that many babies 
in whom one can find nothing whatever to criticize have a slight 
rosary, a slightly delayed closure of the fontanel, and a some- 
what tardy dentition. In the majority of cases the rachitic 



246 PRACTICAL INFANT FEEDING 

process, if one really can call it such, never goes any further, 
but it is a good plan to give such babies cod-liver oil in doses 
of 15 or 20 drops three times a day, and to watch carefully for 
any further signs of rickets. 

FEEDING DURING THE SECOND YEAR 

In general, mothers are altogether too prone to feed babies 
of this age too great a variety of foods. A baby does not need 
a particularly varied diet; if he is normal mentally and phys- 
ically he goes contentedly along from day to day on very much 
the same general plan of diet. The modem tendency is to 
introduce too many articles of food into the dietary at altogether 
too early an age, and is the biggest part of the reason why babies 
get into so much trouble during the "second srnnmer." Most 
babies will flourish on milk, cereals, zwieback, soup, or beef 
juice and orange juice until they are fourteen months old, and 
there is no advantage in giving them anything else. Cereals 
should be taken with a little milk poured over them, but with 
no sugar. While it is probably true that a small amount of 
sugar on the cereal does not at the time do any harm, it is not 
wise to get the child in the habit of taking sweet things, and if 
he is not used to sugar, he never misses it. The best cereals 
for babies are barley jelly, farina, oatmeal, or rice. Babies 
usually like soup. Whether or not it is of any real value is 
doubtful. If it has any value, it is probably due to the small 
amount of iron that it may contain, and it is well to have soup 
made with carrots or spinach cooked in it, and then strained out 
again, to get whatever advantage there may be in this. A neck of 
lamb is as good as anything from which to make soup, and has the 
advantage of cheapness. A pound and a half will make a pint 
of good soup. Usually not more than 3 or 4 ounces of soup is 
given at a feeding, with the noon meal, and a tablespoonful of 
rice or pearl barley (measured when cooked) is given with it. 
Beef soup is not so digestible as lamb or chicken. Zwieback 
or dry bread is valuable, and part of the daily ration of zwieback 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 247 



Date. 



Diet List for. 



BREAKFAST 



LUNCH 



DINNER 



SUPPER 



Total Calories. 



Fig. 4. — Diet card. 



ought to be given dry, as it teaches the baby to chew. In 
planning a diet for a baby it is much better to put down on paper 
for the mother exactly what he is to have, and exactly when he 
is to have it, than merely to write down or to give instructions 



248 PRACTICAL INFANT FEEDING 

verbally. For some years I have used cards of 5 x 8 inches, one of 
which is reproduced on p. 247. These can be mailed, with every- 
thing put down in black and white, so that there is no chance 
for a mistake, and are especially convenient for use after the 
mother has called up to inquire about the diet over the tele- 
phone, or for those patients whose feeding is being regulated by 
letter. 

Beef Juice. — ^The chief value of beef juice is to furnish iron. 
It also contains a certain amount of protein (about 6 per cent.). 
It is best given at the noon meal poured over bread, toast, or 
potato. Not more than 2 ounces a day should be taken. 

Green vegetables may usually be started safely at fourteen 
months, and should always be strained through a fine sieve, so 
that they are in the form of a fine paste. The best vegetables 
to use are spinach, carrots, string beans (if tender), and peas. 
The chief value of the green vegetables at this age is to add 
bulk to the diet and also to furnish iron. Portions of any vege- 
table, particularly spinach and carrots, always come through in 
the stools, and this is of no moment unless a diarrhea is caused, 
in which case the vegetables should be discontinued until the 
child is a little older. The vegetables are usually given at the 
midday feeding, mixed with soup and rice. In some cases, if 
the baby is anemic, I add the grated yolk of a hard-boiled egg for 
the iron that it contains. 

The foregoing is a middle stand with regard to the vegetable 
question, and while I do not believe that young babies should 
take them, neither do I believe that they should be withheld 
until the end of the second year, or even later, as some authors 
advise. When a baby gets to be fourteen or fifteen months old 
he needs a fairly bulky diet, and the addition of vegetables 
brings this about, and thus minimizes the danger of feeding him 
too much starchy food. At fourteen months a w^ell baby would 
be on the following diet. 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 249 

6.30-7.00 A. M. (on waking) : Milk, 8 ounces. 
9.00 A. M.rlOrange juice, 2 ounces. 
10.30 A. M.: Cereal, 1 cupful. 

Milk, 8 ounces. 
2.00 P. M.: Soup, 4 ounces, or beef juice, 2 ounces. 

Green vegetable, 2 tablespoons ) mixed 

Strained rice, 2 tablespoons j together. 

Junket. 

Milk as much as he wants, with a slice of stale bread. 
6.00 p. M. : Milk toast or zwieback softened in milk. 

Apple or prune sauce, 2 tablespoons. 

Milk, 8 ounces. 

Potato and Eggs. — Many babies digest potato with diffi- 
culty, and they are usually so fond of it that they often take a 
good deal more than they should. We have all seen babies who 
take a baked potato every day at one year, and thrive on it, 
but, in general, it is best to wait until sixteen months before 
starting it. Baked potato is the most digestible form, and one 
potato a little larger than an egg may be taken every other day, 
with a little milk poured over it. It is best not to give potato 
on the same day that the green vegetable is given until a baby 
is about 2 J years old. A number of babies have an idiosyncrasy 
to egg, and when the first taste of egg is given will break out 
with an urticarial eruption, and may be violently sick. Other 
babies have no idiosyncrasy to egg in the sense of allergy, but 
it merely upsets their digestions and causes diarrhea or 
vomiting. In the first case the trouble is usually due to the 
white of the egg, and if skin tests are done it can easily be 
determined whether the white or the yolk, or both, are at fault. 
If the idiosyncrasy is to the white alone, the yolk may be given 
hard boiled and grated, mixed with the green vegetable and rice. 
In a great many cases after a few months the child will be able 
to take the white without trouble. If not, it is possible to 
desensitize by feeding very small doses of powdered egg-white. 
In the second case it is best to wait a few weeks, and then try 
the egg again in small doses. 

Egg should be always started in small portions, a teaspoonful 
at a time, until one knows how the baby is going to react to it, 



250 



PRACTICAL INFANT FEEDING 



then as he becomes used to it he can take one egg every other 
day, usually at the 2 o'clock feeding. 

Diet from Sixteen Months to Two Years 

6.30-7.00 A. M. : Milk, 8 ounces, with a small cracker. 
9.00 A. M.: Orange juice, 2 ounces. 
10.30 A. M.: Cereal, 1 cupful. 
Milk, 8 ounces. 

One day. The next day. 

2.00 p. M.: Soup, 3 to 4 ounces. Soup, 3 to 4 ounces, or beef juice, 1 

Potato, egg. to 2 ounces. 

Junket. Green vegetables, 2 tablespoons. 

Milk(?). Rice, 2 tablespoons. 

Custard. 
Milk(?). 

Bread and butter. 
6.00 P. M. : Milk-toast or zwieback and milk, or bread and jelly sandwiches, 
or macaroni. 
Apple or prune sauce or stewed pears. 
Milk. 



Diet for a Child of from Two to Three Years 

8.00 a. m.: Cereal. 
Egg. 
Toast. 
Milk. 
11.00 A. M.: Milk, 8 ounces. 

One day. 
1.30-2.00 P.M.: Soup(?). 

string 

beans, 
spinach. 
< carrot, 
squash, 
peas, 
turnip. 
Rice or macaroni. 
Bacon. 

Tapioca pudding, junket, or custard. 
6.00 P. m. : Milk-toast or zwieback and milk, or bread and jelly sandwiches. 
Cereal occasionally. Milk. Apple-sauce, prune sauce, baked 
apple, or stewed pears. 



Vegetable 



The next day. 
Soup(?). 
Vegetable. 
Potato. 

{chicken, 
beef, 
lamb. 
Tapioca pudding, junket, or custard. 



At about two years the baby begins to have a regular 
breakfast at 8 o'clock instead of his early bottle. Meat and 



J 



THE ARTIFICIAL FEEDING OF THE NORMAL INFANT 25 1 

bacon can be added to the diet at this age. The meat should 
be finely scraped, and may be chicken, lamb, or beef. Beef is 
the least digestible of these three. Crisply cooked bacon can 
be alternated with the meat, and either the meat or bacon is 
mixed with the vegetables and rice or potato. 

A child's wishes should not be consulted or catered to in the 
matter of diet. It is common for children to refuse new articles 
of food offered, and if the mother is not persistent in the be- 
ginning she may have the greatest difficulty in getting the child 
to eat certain things. The child who "doesn't like this" and who 
"can't eat that" should not be seen in a well-regulated family. 
Many of the dietary troubles that occur in children from three 
to six years of age have their origin in the first three years when 
on accoimt of the fact that the child at first refuses certain 
articles, he is never thereafter urged to eat them, and his poorly 
balanced diet is made up entirely of things which he does Uke, 
such as, perhaps, toasted corn flakes, potatoes, or milk. 



CHAPTER X 

DIGESTIVE AND NUTRITIONAL DISTURBANCES IN THE 

BOTTLE FED 

(1) The science of infant feeding is a young one. (2) The 
problems involved in a consideration of the disturbances that 
may arise when a baby is being artificially fed are often ex- 
tremely complicated. For these two reasons we know even now 
comparatively little about the exact nature of these disturb- 
ances, and it has not always been possible to keep speculation 
and fact as far apart as they should be kept. Hence there have 
been, as we have seen in the chapter on the Development of 
Modern Infant Feeding, various opinions regarding the nature 
of these disturbances, many of which have been discarded as 
knowledge has progressed. Our information is constantly being 
added to, and it must by no means be though that we have yet 
reached the stage where we have a fixed or even a satisfactory 
knowledge of the many problems involved. Development in 
different localities has been along divergent lines, and widely 
separated opinions have been held by various investigators, who 
have used different methods of nomenclature and classification. 
This has not tended to make the subject clearer to the casual 
student. In what follows I shall not try to follow any one 
school, but to present what seems to me to be a practical con- 
ception of the disturbances of digestion and nutrition in infancy 
in accordance with the present state of our knowledge. The six 
following propositions are fundamental: 

1. The artificially fed baby is prone to digestive disturbance 
because cow's milk is chemically and biologically different from 
the food that nature intended him to take, and because it may 
be richer in bacteria. 
252 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 253 

2. Rarely is the disturbance primary in the digestive tract; 
it is not the digestive tract or its secretions which are at fault, 
but the food which is offered. 

3. In considering the disturbances of digestion and of nutri- 
tion it is necessary to bear in mind that the food is made up of 
fat, sugar, starch (sometimes), protein, and salts, and to be able 
to trace the special sort of damage that may be caused by any 
one of these food elements individually. It has been found by 
experience that the different food elements may cause different 
sorts of disturbances, with S3m[iptoms which are, to a certain 
extent, characteristic of each element. 

4. Not only is a consideration of each individual element 
important, but the quantitative relationship of these in the food 
offered must always be borne in mind, and while any given 
element in a certain amount might be harmless in one com- 
bination, it might cause considerable disturbance when offered 
in another. 

5. Bacteria within the digestive tract can never be separated 
from problems of digestion and nutrition. These bacteria may 
be those which are normally inhabitants of the intestine, or may 
he introduced from without in infected milk. Bacteria play 
little part in gastric disturbances, but many times play the 
major role in intestinal indigestions. // there is a residue of 
food which the baby is incapable of digesting and assimilating, this 
food is attacked by bacteria, and excessive fermentation or putre- 
faction results, which gets the baby into trouble. This is one of 
the most potent of aU sources of disturbance in artificially fed 
babies. Also if bacteria are introduced from without, and are 
present in the upper portions of the intestine, where they should 
not be, the same result occurs. If is often not possible to tell, 
in intestinal disturbances, how much of the trouble is due to 
bacterial decomposition of the food and how much to undigested 
food alone. 

6. Acute disturbances, if checked, usually carry with them 
little disturbance of nutrition or of the body as a whole; they 
are localized in the digestive tract, and may be correctly spoken 



254 PRACTICAL INFANT FEEDING 

of as * 'indigestions." Chronic disturbances often bring about 
severe nutritional damage, and an abnormal metabolism of the 
whole body. These are true disturbances of nutrition, and, as 
Czerny and Finklestein in particular have pointed out, may be 
looked upon as metaboKc diseases, in the same way that diabetes 
is a metaboHc disease. Here we are deaKng with an indigestion 
plus far-reaching general bodily damage. 

Classification and Nomenclature. — There is no subject in 
medicine at present in which a looser nomenclature is used than 
in infant feeding. If one studies the ten or a dozen text-books 
of infant feeding that are written in English, he will soon see 
that there is little uniformity of expression. This is a pity, as 
it tends to cause confusion. Clear and uniform classification 
and nomenclature are essential in any scientific subject. The 
two great dangers in any classification are those of including 
too many somewhat similar phenomena under one heading, or 
of splitting apart the subject into too many divisions, several of 
which might be better confined under one heading. A satis- 
factory classification strikes a happy medium between these two 
extremes. A satisfactory classification should serve at the same 
time as a system of nomenclature. It is true that one can 
correctly divide digestive disturbances in babies, as Marfan has 
suggested, into vomiting, diarrhea, constipation, and failure to 
gain. Such a classification includes all the cases seen, but is 
entirely unscientific, and is of no value in giving us a closely 
fitting descriptive name to apply to any given condition that we 
see before us. 

It is possible to classify any group of phenomena or objects 
in a number of different ways; that is, metals or woods may be 
classified according to their hardness, color, weight, or innum- 
erable other qualities. Likewise, it is possible to group digestive 
disturbances in infants according to their etiology, pathology, 
or clinical symptomatology. This has been done in the past, 
and there are at present in use classifications on all these bases, 
or on combinations of them. Any division has overlappings; in 
a classification of the sciences geology borders on physics and 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 255 

chemistry; zoology, on botany; chemistry, on physics. It is 
likewise not possible in constructing a classification of the 
digestive disturbances of infants to do away with overlapping; 
there will always be borderline or mixed cases, no matter what 
method of classification is used. The three bases of classifica- 
tion that have been employed are those of pathology, clinical 
symptomatology, and etiology. A practical work of this sort 
is not the place for a detailed discussion of the advantages and 
disadvantages of each one of these groupings; it may be said 
that inasmuch as there are often no pathologic lesions to be 
found in babies dead of gastro-intestinal or nutritional disease, 
the pathologic classification cannot be accepted as a satisfactory 
one. The clinical classification has many good points, but since 
it is true that many times the same clinical picture may be 
produced by rather widely different etiologic agencies, it is open 
to objection on this score. The best classification is one which 
arranges its objects in a definite plan, which can also serve as a 
system of nomenclature, and which is best adapted to the pur- 
poses in view. In this particular instance the ultimate purpose 
in view is treatment. 

The etiologic classification fulfils these requirements. It has 
its defects, but has fewer defects and more good points than 
either of the others. It includes all cases, it gives us a very ser- 
viceable nomenclature, and especially does it focus our attention 
on the individual food elements, and gives us suggestions for treat- 
ment. In many medical subjects an etiologic classification is 
not at all serviceable, but in the subject under discussion, 
where a careful consideration of each food element is so impor- 
tant, and where it is so necessary to know what symptoms each 
one produces, an etiologic nomenclature makes the subject much 
more clear. Therefore, let us speak of digestive disturbances in 
terms of the food element that is the most active in causing the 
trouble. 

The following classification has its origin in that of Czerny, 
and with the exception of a few slight changes is the same as 
that used in the Harvard Medical School (1921). It is by no 



256 PRACTICAL INFANT FEEDING 

means perfect, but will be found serviceable as a practical 
working basis: 

1. Underfeeding 

2. Acute fat indigestion 

3. Acute sugar indigestion 

4. Acute protein indigestion 

5. Acute starch indigestion 




6. Chronic fat indigestion { ^^^ ^ ^ = -— — ^ Marasmus 



7. Chronic sugar indigestion 

8. Chronic starch indigestion 

The acute indigestions carry with them little disturbance of 
nutrition; the chronic forms, if severe, are accompanied by 
severe nutritional damage. The condition called "marasmus," 
which represents simply an extreme degree of malnutrition, may 
be brought about by prolonged underfeeding or by any one of 
the chronic indigestions if severe enough and if continued over a 
long enough period of time. It is a condition so distinctive, and 
possessing such especial characteristics, that it is best to look 
upon it as an end-result of prolonged digestive insult, and to 
realize that much the same final result may be produced whether 
it has been caused by underfeeding, or by starch, sugar, or fat, 
than to speak of it as a severe chronic indigestion of any one type. 

Underfeeding. — This condition is not so common as many of 
the other disturbances, as the great tendency at present is 
rather to overfeed babies than to underfeed them. It is seen 
especially in babies who have been fed on proprietary foods, or 
on condensed milk mixtures, where the calories offered have not 
been enough to promote normal weight and growth develop- 
ment. It is seen in cases where the physician has prescribed 
during the early weeks of life a modified milk mixture low in 
fat and in protein, and has then lost track of the baby for several 
months. The baby has had no symptoms of indigestion, and 
has seemed to be doing fairly well, so the mother has continued 
with the same food, and the child is taking at seven or eight 
months a food which was adequate for him at one month, but 
which is not now sufficient. Another type of underfed baby is 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 257 

one which has been fed over a considerable period of time on 
barley-water, or perhaps barley-water with a small amount of 
milk added. This is likely to be seen among the ignorant classes, 
where many mothers have a firm belief in the nutritive powers 
of barley-water. It is, of course, a very weak food. 

Babies who have been underfed may vary a great deal in 
their appearance and in the severity of their condition, according 
to the degree and time of underfeeding. Many are only slightly 
underfed and only a little below average weight. They are 
rather flabby, with poor color and tissue turgor, and may or 
may not have signs of rickets. Their digestive powers are little 
if at all impaired, and they respond readily to treatment. The 
more severe cases may present the picture of extreme mal- 
nutrition. They are much emaciated, small in size, with small 
bones, and flabby, inelastic tissue. Their tolerance for food is 
low, largely because their digestive powers have never been 
developed, and partly because bacteria are likely to flourish high 
up in the digestive tract and either ferment or putrefy any 
undigested food residue. 

Treatment. — The treatment of the milder cases is not at all 
difficult. It consists merely in increasing the caloric value of 
the diet. This should be done rather slowly, in order to gradually 
accustom the digestive tract to stronger food. The food is 
increased until it is sufficient to cover the caloric needs, and to 
bring about a gain in weight. If the baby is over eight or nine 
months old, the addition of other articles of diet, such as cereal, 
zwiebach, or beef juice, is often of value. The severe cases are 
much more difficult, as the food tolerance is low, and symptoms 
of indigestion are very likely to occur as the caloric value of the 
diet is increased. The best plan to follow is first of all to in- 
crease the protein to an amount which is sufficient, then the fat 
and sugar. The fat tolerance is almost always poor in this 
class of babies. If the sugar tolerance is good, much benefit 
often results from feeding a high sugar. One element only should 
be raised at a time, and it is likewise well not to increase the 
strength and the amount of the food at the same time. By 
17 



258 PRACTICAL INFANT FEEDING 

increasing only one food element at a time it is much easier to 
tell what has upset the baby if difficulties occur. If symptoms 
of indigestion are caused by the increase in diet, they should be 
treated with the proper treatment for that type of indigestion. 

Acute fat indigestion is caused by overfeeding with fat, 
either as too high a percentage of fat, or as too much total food. 
There are very few babies who can take more than 4 per cent, 
of fat, and most small babies cannot take even this amount. 
Acute fat indigestion is especially likely to be seen in babies- 
under two or three months of age, but may occur at any age. 
Vomiting of sour, thick, creamy material is one of the first 
symptoms. This is usually combined with loose, greenish- 
yellow stools, usually, but not always, acid in smell and reaction, 
which contain many large and small undigested fat curds. The 
number of stools is usually from three to six a day, and the 
buttocks soon become excoriated by them. The gastric dis- 
turbance is probably caused by the irritating free fatty acids 
in the excess of fat given, without the intervention of any bac- 
terial processes, the diarrhea by the irritant action of the 
unabsorbed fat on the intestinal mucosa, and also probably by 
a certain amount of bacterial decomposition of the fat. The fat 
in the stools is usually in the form of fatty acid or soap, but in 
cases in which the overfeeding with fat has been excessive, the 
stools may be loaded with neutral fat. Under these conditions 
they are Ukely to be of a bright yellow color and oily consistency. 

Treatment, — In any acute indigestion it is always well to 
stop milk for a few hours. The baby should be put on a weak 
barley-water decoction for six or eight feedings in order to rest 
the digestive tract. It is well also to give a dose of castor oil 
in order to thoroughly empty the intestine. The subsequent 
feeding can be either one of the following: 

1. Boiled skimmed milk dilutions. 

2. Protein milk (see Chapter IX). 

If the stools are not very loose or frequent, and show Httle 
green coloration, the first method of feeding is satisfactory, and 
is much more simple than the second. A few ounces of the 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 259 

barley-water feeding may be replaced by an equal number of 
ounces of skimmed milk, and the whole boiled together for ^ve 
minutes. Usually about one-half barley-water and one-half 
skimmed milk would be employed in babies over two months 
old, giving a formula of fat .00, sugar 2.25, protein 1.60.^ With 
younger babies a more dilute formula would be used, with water 
as a diluent instead of barley-water. The baby is kept on this 
feeding for a day or two, until the stools begin to improve, when 
sugar can be added, and lastly fat, rather cautiously, until an 
amount of fat is reached about equal to whatever amount of fat 
he had been previously doing well upon. 

The duration of symptoms, and the time it will take to get 
the baby back to a diet upon which he can gain weight, depends 
entirely upon the severity of the case, and the time over which 
excessive fat feeding had been going on. 

If the stools are very loose and green, not at all homogeneous, 
and contain a good many large soft curds, it is probable that a 
certain amount of sugar indigestion is associated with the 
primary fat trouble. In this case the first method of feeding is 
not as efficient as protein milk feeding (Finkelstein's original 
protein milk, a laboratory prepared precipitated casein mixture, 
or "larosan" or "casec" milk). With this method of feeding it 
is not usually necessary or desirable to remove the fat entirely, 
but a rather low fat is given in combination with a high protein 
(in precipitated form). In a couple of days this feeding pro- 
duces, in most cases, smooth, rather constipated, putty-like 
stools. When this stage is reached, sugar may be added, and it 
ought to be possible in m_ost cases to gradually work the baby 
back to an ordinary milk modification containing a rather low 
fat percentage in a few days. 

Acute Sugar Indigestion. — It is probable that it is not possi- 
ble for acute sugar indigestion to occur without a certain amount 
of bacterial fermentation of the sugar. Therefore acute sugar 
indigestion is very similar to fermentative diarrhea (see next 

^ This is the minimum. Often it is desirable to use a much greater con- 
centration of skimmed milk than this 



26o PRACTICAL INFANT FEEDING 

chapter). Sugar is the most easily fermentable by bacteria of 
all the food elements, and any unabsorbed sugar residue, whether 
present in the intestine on account of poor sugar digestion or 
overfeeding with sugar, is almost sure to be attacked by bacteria 
and fermented. There is no sharp distinction between sugar 
indigestion and fermentative diarrhea; they both represent, in 
reahty, the same process, although they may be brought about 
in somewhat different ways. Sugar indigestion is a condition 
of relatively mild sugar fermentation; fermentative diarrhea, a 
severe one. In the second condition the products of excessive 
bacterial decomposition dominate the picture, and the stools 
are very loose and contain a great deal of mucus, and sometimes 
pus. In sugar indigestion these manifestations of extreme 
irritation of the intestine do not result. Sugar indigestion 
usually results from overfeeding with sugar, the unabsorbed 
portion of which is fermented by the bacteria normally present 
in the intestine — fermentative diarrhea usually from bacteria 
introduced from without in bad milk, or bacteria swallowed in 
abnormal nasal or pulmonary secretions. Sugar indigestion 
occurs at any time of the year; fermentative diarrhea, usually 
in the summer. In the Finkelstein classification both of these 
conditions would be grouped under "dyspepsia," and it is true 
that the somewhat indefinite distinction between them is a 
defect of the etiologic system of classification. The term 
"sugar indigestion" is then reserved for the milder forms of 
sugar fermentation; "fermentative diarrhea," for the more 
severe. A sugar indigestion is very likely to begin with the 
spitting up of thin watery material. This is particularly true 
if malt sugar preparations are used, and often a more severe 
disturbance may be prevented by recognizing this premonitory 
symptom and cutting down the sugar in the diet before intes- 
tinal symptoms have had a chance to develop. Most of the 
disturbance in sugar indigestion is, however, intestinal, and is 
shown by the passage of loose, green, acid stools, containing 
usually moderate amounts of mucus, and many small white 
curds of undigested fat, which has been hurried through the 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 261 

intestine so fast by the increased peristalsis that digestion and 
absorption could not take place. These stools smell strongly- 
acid, react acid to litmus-paper, and cause red, blistered buttocks. 
The baby is usually not very sick; he may, however, be fretful, 
have a certain amount of abdominal distress, and perhaps a 
degree or two of temperature. The mechanism of the produc- 
tion of acute sugar indigestion is that the undigested sugar is 
being attacked by bacteria either in the large or small intestine, 
is fermenting, and the acids, such as acetic, butyric, and formic, 
which are formed as a product of the fermentation, irritate the 
intestinal mucosa and cause an increased peristalsis, with loose, 
undigested stools. 

Treatment. — ^A very mild sugar indigestion, where perhaps 
there have been only two or three moderately loose acid stools 
for a day or two, may be often successfully treated by simply 
diluting the modification with one-half water for a few feedings, 
by omitting added sugar from the modification, leaving the rest 
of it as it was before, or by withdrawing milk entirely for a day, 
and substituting a weak barley-water decoction. The reduction 
in the amount of sugar ingested is enough to stop the fermenta- 
tive processes which are taking place, and to restore the normal 
bacterial balance of the intestine. This suffices, however, for 
only the mildest cases; all others should be treated by a radical 
change in the character of the food. The objects of treatment 
are first to empty the digestive tract of as much of the fermenting 
material as possible, and then to change the food in such a way 
that no more fermentarion of sugar will take place. By with- , 

drawing sugar, the material that is fermenting, and by substi- | 

tuting protein in relatively large amoimts, a food which is not 
likely to be attacked by the same sorts of organisms that are 
attacking the sugar, and which is likely to set up an alkaline 
condition in the intestine instead of the excessively acid one 
already present, the desired purpose may be accomplished. A 
food containing a small amount of sugar and a relatively large 
amount of protein, such as Finkelstein's protein milk or one of 
its modifications or substitutes, fulfils these indications. It is 



262 PRACTICAL INFANT FEEDING 

often a temptation to try to treat these cases by simply with- 
drawing sugar from the modification instead of changing the 
entire character of the food, but this is a mistake except in the 
very mildest cases, and much time will be saved if a low sugar, 
high protein milk is used from the beginning. 

Details of Treatment. — 1. Castor oil, 2 teaspoons. 

2. Finkelstein's protein milk, dried protein milk, larosan 
milk, precipitated casein milk, or lactic acid milk dilutions, 
according to the circumstances of the case. A preliminary star- 
vation with barley-water is not usually necessary in simple 
sugar indigestion. After a couple of days of feeding on the high 
protein milk the stools should become decreased in frequency, 
salve-like in consistency, and gray in color. When this stage 
has been reached, sugar may be gradually added, 2 per cent, at 
a time, until 6 or 7 per cent, has been reached. Dextrimaltose 
is the best sugar to use for this purpose, as it is less easily fer- 
mentable than lactose. In the ordinary case, where the baby 
has previously been healthy, it is not necessary to keep up the 
protein milk feeding for more than a week or so, when a feeding 
of the ordinary milk modification, with a rather lower sugar than 
it contained before, may be substituted for a bottle of the 
protein milk. Daily substitutions may be made until the pro- 
tein milk is omitted entirely, and the baby is back again on a 
simple modification. 

In the case of babies who have had repeated attacks of sugar 
fermentation it may be necessary to continue the protein milk 
over a period of several weeks. 

Drugs. — Theoretically it should be of advantage to give by 
mouth some alkali which would aid in neutralizing the excessive 
acidity in the intestine. Practically, precipitated chalk seems to 
help a good deal, and \ teaspoonful can be given in each bottle 
of milk that the baby takes. 

Results. — The results of proper treatment in acute sugar 
indigestion are most gratifying, and, treated properly, the con- 
dition offers little difficulty. Treated improperly, it is most 
stubborn, is prone to become more severe, or to turn into a 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 263 

chronic condition. Repeated attacks of acute sugar indigestion 
may be responsible for much nutritional damage. 

Acute Protein Indigestion.— Acute indigestion from protein 
is not uncommon. Although it may cause a considerable dis- 
turbance for a short time, it is easily remedied, and is not pro- 
ductive of the far-reaching nutritional damage that sometimes 
follows indigestion of the other food elements. 

Cow's milk is rich in casein, which coagulates in the stomach 
in large tough masses. K too high a percentage of protein is 
fed, casein indigestion may result. The chief symptom is 
vomiting of large, tough, irregularly shaped masses of undigested 
coagulated casein. I have seen these masses so large that they 
nearly choked the baby when he attempted to vomit them. 
Casein indigestion is seen in small babies who are taking too 
high concentrations of whole milk, and in older babies sometimes 
who have been put on an undiluted milk before they are ready 
for it. The disturbance is mostly gastric, but often undigested 
portions of casein find their way into the intestine and appear in 
the stool as small bean-like lumps, the characteristic "casein 
curds." These vary from the size of a barley grain to that of a 
large lima bean, and are of a rather yellowish color. They are 
tough in consistency, sink in water, and become very hard when 
placed in formalin. Their appearance is quite characteristic, 
and when once seen cannot be mistaken for anything else. 
These casein curds may act as mechanical irritants and may thus 
cause increased frequency of the movements. There is little if 
any bacterial action concerned in casein indigestion; the essential 
nature of the process is that the tough masses of coagulated casein 
cannot be digested, and thus cause irritation of the gastro- 
intestinal tract. The German School does not recognize any 
such thing as protein indigestion, but in our opinion it undoubt- 
edly occurs, especially in babies who are fed on raw milk. The 
probable reason that German investigators have paid so little 
attention to protein indigestion is that on the Continent milk is 
boiled as a routine, which tends to make soft curds in the stomach 
instead of hard ones. Often in the stools of normal babies who 



264 PRACTICAL INFANT FEEDING 

are apparently not suffering from indigestion a few small casein 

curds may be seen. In these cases boiling of the milk or slight 

reduction of the percentage of protein in the food will cause them 

to disappear. 

Treatment. — In accordance with the general principle of 

withdrawing milk from a vomiting baby, it is well to begin 

the treatment of an acute protein indigestion by putting the 

baby on barley-water for twenty-four hours. In most cases the 

regular diet may then be gradually resumed and curd formation 

prevented either by reducing the amount of protein, by boiling 

the milk, or by the addition of lime-water or sodium citrate to 

the formula. A reduction of the amount of protein and the 

addition of an alkali is usually the most efficient method. In 

using lime-water it must be remembered that it must be added 

in an amount equal at least to 25 per cent, of the milk and 

cream in the mixture. The practice of adding small amounts 

of lime-water, which is so commonly followed, does no good 

whatever. Sodiimi citrate is probably no more efficient than 

lime-water, but is far more convenient to use, as its bulk is not 

so great. Ordinarily 1 grain of this for each ounce of milk and 

cream in the mixture is sufficient. I am in the habit of giving a 

prescription containing 20 grains of citrate to the teaspoonful, as 

follows: 

Sodium citrate 5 j ; 

Water ad. 5iv. — M. 

S. — One or 2 teaspoonfuls to the day's feeding. 

Results should be uniformly good. A very few babies seem 
to have an idiosyncrasy to protein and need always to be fed 
small amounts of it. The vast majority of babies, however, 
have a very good tolerance, and even if this tolerance is over- 
stepped, the resulting disturbance is not difficult to correct. 

Acute starch indigestion is occasionally seen in babies from 
six to ten months old who are first beginning to take cereal, or 
in younger babies with whom the mistake has been made of 
giving too large amounts of starch at too early a period. It is 
almost entirely an intestinal indigestion, and the symptoms are 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 265 

due partly to bacterial decomposition of the starch, and partly 
to its action as an undigested foreign body in the digestive tract. 
The stools are usually increased in number (three to six a day), 
are of a thin, mushy consistency, of a brownish-oHve-green color, 
and usually of an acid reaction. They often contain small 
gelatinous masses of undigested starch, and are not smooth in 
consistency, as a normal stool should be. In some cases, where 
the starch is simply acting as a foreign body, and no bacterial 
decomposition has taken place, they are likely to be brownish 
in color, large in size, and of a hard consistency, which causes 
constipation. In both groups of cases the stool turns bluish 
black when an iodin solution is added, and imder the microscope 
large black masses of undigested starch are seen. The treat- 
ment consists in omitting starch from the diet for two or three 
weeks, and then starting in again with smaller amoimts. The 
proper cooking of starch is very important; the starch grains 
are not broken down if they are not cooked long enough, and if 
they are not broken down they are Hkely to be indigestible. 

THE CHRONIC INDIGESTIONS 

Chronic Fat Indigestion. — Chronic indigestion from fat may 
result from the fat alone, from fat given with a wrong propor- 
tion of the other food elements, or from undigested fat plus the 
action of bacteria upon it. It is the most common t3^e of 
chronic indigestion, the most complicated chemically, the 
most far-reaching in its results as regards severe nutritional 
disturbance, and the most difficult to treat successfully. 

Let us briefly review the digestion and absorption of fat. 
Fat as it exists in milk is what is known chemically as a neutral 
fat; that is, a combination of fatty acid and glycerin. A small 
amount of the fat is split into its component parts in the stomach, 
but most of the fat digestion is carried on in the intestine. There 
it is broken down into fatty acid and glycerin by the steapsin of 
the pancreatic juice. The fatty acid combines with an alkali 
in the intestine (calcium, magnesiima, sodium, or potassiiun) to 
form a soap, is emulsified by the bile, and absorbed as a soap. 



266 PRACTICAL INFANT FEEDING 

The calcium and magnesium soaps are relatively insoluble and 
are absorbed with difficulty, the sodium and potassium soaps 
are soluble and are absorbed with ease. What fat is going to do 
in any given intestine depends very largely upon the reaction of 
the intestinal contents and the rate of peristalsis. If peristalsis 
is slow and the reaction is alkahne, calcium soap formation 
results, with constipation and characteristic nutritional dis- 
turbance. If fermentative bacteria are acting upon the fat, 
fatty acids are formed, which stimulate peristalsis and cause 
loose, acid, curded stools. 

If a high fat is fed in combination with a high protein the 
first picture is likely to result; if in combination with a high 
sugar and low protein, the second picture may occur. In deal- 
ing with fat indigestion, as with any indigestion, macroscopic 
examination of the stool is of the utmost importance. Micro- 
scopic examination is also of much value if interpreted cor- 
rectly, but may lead the inexperienced infant feeder far astray 
if he has not a thorough understanding of the subject. Micro- 
scopic examination of the stool for fat has been greatly overdone, 
and has undoubtedly caused much harm. The physician finds 
fat in considerable amount under the microscope, immediately 
diagnoses a ''fat indigestion," cuts all fat from the diet, and 
the baby often is unnecessarily underfed as a result. It must 
be remembered that the normal stool is made up very largely 
of a residue of unabsorbed fat in the form of soap; furthermore, 
that young babies always show much more fat in the stools 
than older children do. The finding of a large amount of fat in 
the stools of a young baby may be, therefore, of Kttle significance 
when it would be of considerable import in an older child. It is 
also of Httle value to look for fat in very loose stools, as a large 
amount of unabsorbed fat always comes out in these stools as 
a result of the increased peristalsis, and does not necessarily 
mean that the primary disturbance was due to fat; it may have 
been due to anything which caused a diarrhea. If a baby is 
having one small stool a day, and it is full of fat under the 
microscope, it may be of no significance; if he is having two or 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 267 

more large stools a day which show microscopically an equally 
large amount of fat, his fat absorption is probably poor, and he 
is losing more fat in his stool than he should. The amount of 
fat seen in the stool is of significance only when taken in con- 
junction with other data, such as gain in weight, general con- 
dition, the type of food fed, number and consistency of stools, 
etc. If a baby were doing well I should care very Httle whether 
his stool showed large amounts of fat or not; if he were doing 
poorly I might pay attention to excessive fat in the stool, or 
might not, depending entirely upon the circumstances of the 
case. The amount of fat seen microscopically in the stools of 
normal babies varies a great deal; some babies always pass 
stools which contain very small amounts of fat, others have 
stools which are always full of fat. The method of feeding has 
a good deal to do with this, as Grover has pointed out. If a 
baby is fed on a gravity cream and skimmed milk mixture, with 
a relatively high fat and low protein, most of the fecal residue 
will, of course, consist of fatty material; if he is fed on a food 
relatively low in fat and high in protein, the fecal residue will 
contain relatively less fat on account of the larger amount of 
protein residue that comes through. If the baby is not gaining, 
despite an apparently high enough caloric intake, large amounts 
of fat in the stool are of significance, and it is probable that his 
trouble is due to fat indigestion. If he is doing well, large 
amounts may have but Httle significance. One of the best and 
at the same time one of the worst things about the Boston 
methods of infant feeding has been microscopic stool examination 
for fat. In some cases it is of great value, and by its proper 
use we can often get a much clearer idea of the case than we 
could otherwise; but it may be interpreted in quite the wrong 
way, and often does more harm than good in inexperienced 
hands. 

For practical purposes chronic fat indigestion may be divided 
into two main types : 

Type 1. With constipated stools. 

Type 2. With loose stools. 



268 PRACTICAL INFANT FEEDING 

It is common in any given case of chronic fat indigestion to 
see both these manifestations at different periods, according to 
the characteristics of the bacterial flora of the intestine at the 
particular time. The first type is associated with a putrefactive 
flora, and there is no fermentation of fat or of sugar, whereas 
the second type has associated with it a fermentative flora, and 
the symptoms are often due in a large measure to bacterial 
fermentation of fat, and probably also secondarily of sugar. 

Type 1. — This is the condition which has been called by the 
German school "disturbed metabolic balance" (Bilanzstorung), 
and is dependent rather upon fat given in improper relationship 
to the other food elements than to an excess of fat in itself. 
It is particularly likely to develop in babies who are fed on a 
food which is relatively high in fat and protein and low in 
sugar, such as the following formula: 

Fat, 3.50; sugar, 5; protein, 2.50. 

It is par excellence the cow's milk disturbance, and breast milk 
produces no condition which can be at all compared to it. 

The chemistry of the condition is rather complicated, and 
many conflicting theories have been brought forward. Without 
going into two much discussion for and against various theories, 
the following seems the most likely pathogenesis: When a food 
relatively high in protein and low in sugar is fed an alkaline 
condition is produced in the intestine. The causes of this are 
that a large percentage of protein favors the pouring out of a 
large amount of pancreatic juice, which is strongly alkaline, that 
the decomposition products of protein are alkaline in character, 
and that a high calcium is inevitably given whenever a high 
protein percentage is used, which also favors alkalinity. The 
relatively small amount of sugar which is given is totally ab- 
sorbed, and there is none left to support the normal fermentative, 
sugar-splitting, acid-producing flora of the intestine. The 
intestinal flora with high protein and low sugar feeding, there- 
fore, becomes putrefactive in type. The higher fatty acids 
formed from fat splitting in such an intestine as this, where 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 269 

peristalsis is slow on account of the lack of fermentation, have 
abundant opportunity to combine with the large amount of 
calcium present to form insoluble calcium soaps, which are best 
formed in an alkaline medium. These calcium soaps cannot be 
absorbed, and form large, dry, hard, light colored stools, which 
contain an excessive amount of fat and of calcium. Thus the 
baby is deprived of a good many calories which he might be 
utilizing if his fat absorption were better, and also is continu- 
ally losing calcium from the body in the form of insoluble calcium 
soaps. Instead of the normal 20 to 25 per cent., from 30 to 60 
per cent, of the ash intake may go out in the stools, and the fat 
absorption may be as low as 60 or 70 per cent. The fat absorp- 
tion is never so poor, however, as it is in diarrhea. As we have 
said before, there are a great many widely varying opinions as 
to the exact chemistry of this condition, but the one given 
above is that which is held by most investigators and the one 
which seems to fit in best with the observed facts. 

Symptoms. — ^The condition is not so likely to be seen in very- 
young babies as it is after the fifth or sixth month. It is slow 
in its development, and there may be for a considerable period 
good gains in weight. Then the weight remains stationary, and 
soon a decline in weight occurs, despite sufficient caloric intake. 
This is an especially important point, and increasing the amount 
of food is likely to be followed by a further loss and an aggrava- 
tion of symptoms, rather than by a gain. The baby becomes 
flabby and pale, and symptoms of rickets may begin to be seen, 
such as profuse sweating about the head, the development of a 
rosary, and a too widely open fontanel. Spasmophilia is not at 
all uncommon in these babies, and may be looked upon as a 
part of the symptom complex, probably caused by an excessive 
withdrawal of calcium from the body. 

The stools are one of the most important characteristics." 
They are large and constipated, of a very light grayish-white 
color, rather foul smelling, and of an alkaline reaction. When 
treated with glacial acetic acid and soudan III and examined 
under the microscope the microscopic field seems to be made up 



270 PRACTICAL INFANT FEEDING 

almost entirely of fat globules. The light color of the stools is 
probably their most important characteristic. This light color 
is caused by reduction processes in the intestine, as when there 
is slight putrefaction in the intestine nascent hydrogen is formed, 
and reduction processes are likely to occur. This reduces 
bilirubin (the ordinary brownish bile-pigment which gives color 
to the stools) to hydrobilirubin and urobilinogen, which are 
colorless.^ 

The more colorless the stools are, the more likely is the 
process to be a severe one, and Bessau regards this colorless 
character of the stools as the most important single characteristic 
of chronic fat indigestion of this type. On account of the con- 
tinued withdrawal of base from the body a relative acidosis is 
produced, with an increased ammonia output in the urine, which 
may smell very anomoniacal. 

Diagnosis. — ^The diagnosis is made by the characteristic 
s3anptoms — ^the fact that loss of weight occurs despite adequate 
or superadequate caloric intake, the character of the food upon 
which the baby is being fed, and the nature of the stools. The 
stools are here very important, and microscopic examination is 
a valuable aid. 

Treatment. — The essential in treatment is to change about 
the putrefaction processes which are going on in the intestine 
and to induce mild fermentation. This is accomplished by feed- 
ing to the baby an entirely different formula, lower in protein 
and fat, and higher in carbohydrate. The carbohydrate is 
raised for two reasons, the first and most important being to 
promote fermentative, acid processes in the large intestine by 
supplying it with a chyme containing carbohydrate, the second 
being the fact that inasmuch as the fat and protein have been 
considerably reduced, it is necessary to feed a high carbohy- 
drate in order to supply sufficient calories. Carbohydrate is 
almost always well borne, and one need not ordinarily be afraid 
of feeding large amounts of it to a constipated baby. It is pos- 
sible to feed larger amounts when several carbohydrates are 
1 Bessau, Jahrb. f. Kinderheilk., 92, 3d series, vol. 42, 1920. 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 27 1 

used than when one alone is given, therefore a combination of 
carbohydrates should be used. Milk-sugar is the sugar which is 
most efficient in producing fermentative processes in the large 
intestine, therefore most of the carbohydrate should be given in 
this form. It has also been found by experience that better 
results are obtained when liquid malt extract and starch are 
used in addition. According to Bessau, the value of malt ex- 
tract lies in the fact that it is partly caramelized. It is hardly 
ever necessary to completely omit the fat in dealing with this 
type of indigestion. It is sufficient to remodel the type of food, 
and to offer one in which the arrangement of the food elements 
is different. Reduction of the protein is of just as much impor- 
tance as reduction of the fat. A great many times physicians 
who are unfamiliar with the chemistry of the condition remove 
all the fat without doing anything else. This gives too low a 
caloric value to the diet, does not correct the underl)dng dis- 
turbance, and thus fails to give good results. In cases where 
the process has been going on for so long that the fat tolerance 
is very low, the baby may be able to take no fat at all. In these 
cases total omission of the fat over a considerable period of 
time, with as great an increase as possible in the protein and 
carbohydrate, may be necessary. 

Example. — ^Let us suppose a six months' old baby was being 
fed on fat 3.50, dextrimaltose 5, protein 2.50. He develops 
tj^ical chronic fat indigestion, with dry, colorless stools. 

Treatment. — The protein should be cut to 1.50 per cent., the 
fat to 2, and the carbohydrate &:st raised to lactose 5, maltose i, 
barley starch 0.75. If this is well borne, it may be gradually 
raised in a good many cases to a total of 8 or 10 per cent. 
Usually not more than 1 per cent, of maltose should be used, as 
more than this has a tendency to cause diarrhea. The addition 
of lactose should also be done cautiously, as it is of course not 
desirable to promote excessive fermentative processes. With 
this feeding, the stools soon become soft, acid, the constipation 
is overcome, and the baby begins to gain in weight. Keller's 
malt soup has been used extensively, with excellent results. It 



272 PRACTICAL INFANT FEEDING 

is essentially a low fat and low protein food, containing a high 
polycarbohydrate (see Chapter IX). 

Type 2. — In this type of chronic fat indigestion the trouble 
results either from a gross overfeeding with fat, or from an 
inability of the baby to digest normal amounts of fat. It is 
often combined with a sugar intolerance. The stools are usually 
loose in character, of a yellowish or of a yellowish-green color, 
acid in reaction,^ with many whitish undigested fat curds. They 
may vary in number from three to six a day, and if they are 
strongly enough acid excoriation of the buttocks may result. 
Vomiting is common in this type of indigestion, particularly in 
those cases where the baby is being grossly overfed with fat. 
The stools may be very oily in character, and when placed on a 
piece of paper may leave a transparent stain in the same way 
that a piece of putty would. Microscopically they contain a great 
deal of neutral fat which has been entirely unspUt. In most 
cases of fat indigestion, however, the fat is usually spHt into 
fatty acid and glycerin efficiently enough, but is not absorbed. 
Fat indigestion of Type 2 differs considerably from Type 1. 
In the latter the intestine reaction is alkaline, and the trouble is 
caused, as we have seen, by fat in improper combination, rather 
than by the fat itself alone. In the former the fat alone is 
usually responsible, the intestinal contents are acid in char- 
acter, and irritate the mucosa, which results in loose movements. 
There may be associated considerable abnormal bacterial fer- 
mentation of fat, and not infrequently of sugar as well. These 
babies rapidly lose appetite, weight, and strength, and after 
the condition has persisted for some time an extreme fat intol- 
erance may develop, and a condition of "marasmus" may result. 
In either type of case the tolerance for fat is low, but is more 
likely to be lower in the second type than in the first. After a 
fat indigestion of either type has been continued for a long time 
the same end-result is reached, however — an extreme intolerance 
for fat, no matter in what combination it may be given. 

Treatment. — ^A complete or nearly complete withdrawal of 
* In some cases the stools may be alkaline. 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 273 

the fat from the diet is usually necessary. This necessitates an 
increase of the other food elements. The protein, in particular, 
should be raised as high as the baby can stand, and babies of 
this type often do well on concentrated boiled skimmed milk 
mixtures. The proper management of the sugar is of great 
importance; it is desirable to give as much sugar as possible 
without producing sugar fermentation. This is sometimes 
difficult, as the sugar tolerance is often poor, and there may be 
associated with the fat incapacity a sugar indigestion. These 
cases should be fed, temporarily, at any rate, on one of the 
protein milk preparations already discussed under Acute Sugar 
Indigestion. The best sugar to use is dextrimaltose, as it fer- 
ments less easily than the other sugars, and the baby can, 
therefore, take more of it without developing sugar fermenta- 
tion than he could of lactose. Starch can also be very advan- 
tageously added to the diet, even with babies who are under 
the age when one would ordinarily begin starch. It is well 
known that even very young babies can digest a Httle starch, 
and 0.75 per cent, of barley starch may be tried in the formula 
in feeding a baby with fat indigestion who is over two or three 
months old. If it does not agree, it is easy enough to discon- 
tinue it. Dried milk has a real place in the treatment of this 
type of case; it is very low in fat, relatively low in sugar, and 
high in protein in an easily assimilable form, and certain cases 
of chronic fat indigestion do remarkably well on it. When a 
level tablespoonful of Dryco Brand dried milk is added to 
8 ounces of water the percentages are: fat 1.5, sugar 5.5, protein 
4.2. In order to cover the baby's theoretic caloric needs it is 
necessary to use 3 level tablespoons of dried milk per day for 
each pound of the body weight (Dennett), Theoretic caloric 
requirements are, however, likely to be misleading in any under- 
nourished baby, as thin babies usually need more than the 
theoretic requirement. Some cases do well on lactic acid milk 
mixtures to which starch has been added, especially if the 
sugar tolerance is low, and there is a tendency to sugar fer- 
mentation. The feeding of homogenized olive oil mixtiures is 

i8 



274 PRACTICAL INFANT FEEDING 

remarkably successful occasionally, and is always worth a trial 
if other means fail. The difficulty in the use of homogenized 
olive oil has been that it is not obtainable outside of large cities 
where there are milk laboratories. The milk laboratories are 
now, however, putting up concentrated homogenized oKve oil in 
mucilage of acacia which may be shipped to a distance, and 
which will keep indefinitely. This preparation is simply mixed 
with fat-free milk in any desired strength in the same way that 
ordinary cream would be. 

Chronic sugar indigestion is common. Its chief character- 
istic is the passage of loose, frothy, green, acid bowel movements, 
usually containing a good many soft white curds and often 
mucus. In some cases regurgitation of thin, watery material 
may also occur without diarrhea, but usually the intestinal 
symptoms are by far the more prominent. The stools usually 
vary from four to six or seven a day, and may be very loose or 
in mild cases merely somewhat spongy or frothy. The buttocks 
soon become much excoriated from the excessively acid stools, 
and loss of weight is rapid, so much so that if the condition 
persists the baby finally gets into a condition of extreme mal- 
nutrition. The essential pathology is a fermentation of unab- 
sorbed sugar in the intestine. This may be due to continued 
overfeeding with sugar, or, more likely, to an inability of the 
baby to digest normal amounts. The intestinal contents become 
strongly acid, and stay so; while the loose movements that 
result prevent the proper absorption of all the food elements, 
especially salts of the alkalies, which partly accounts for the 
steady loss of weight. There is also, besides the sugar fermenta- 
tion, probably in most cases a certain amount of secondary fat 
fermentation, which aggravates the picture. Protein is well 
digested, and any undigested casein in the stools is probably due 
to the rapid peristalsis rather than to any primary indigestion 
of protein. 

Treatment. — The first essential in treatment is to stop the 
excessive fermentation that is going on, and to secure normal 
stools. This must be done before any gain in weight can take 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 275 

place. In mild cases, where the baby is having only a few 
stools a day, and these show only slight evidences of fermenta- 
tion, it may be sufficient to simply cut down the amount of 
sugar or to change the kind of sugar. Often a change from 
lactose to dextrimaltose is efficient, but occasionally instead of 
making the condition better, this change may make it worse. 
In the cases with regurgitation, without intestinal symptoms, 
reduction of the percentage of sugar is usually sufficient. In 
any case of ordinary severity, that is, where there are several 
greenish, sour, curded stools a day, it is always best to begin 
immediately with one of the low sugar, high protein preparations 
(original "eiweissmilch," precipitated casein milk, skimmed milk 
dilutions with powdered casein, lactic acid milk dilutions), and 
it is a waste of time to try to treat the condition in any other 
way. With low sugar and high protein feeding in most cases 
the stools will become smooth and formed in a few days. When 
this stage is reached, small amoimts of sugar may be gradually 
added, and it is often possible to give considerably more sugar in a 
protein milk combination than it is in an ordinary milk formula. 

After the baby has been fed in this way for a few weeks it is 
usually possible to gradually go back to an ordinary formula. 
It is best to start with a simple gravity cream and skimmed 
milk or whole milk formula, which contains not more than 4 
or 5 per cent, of sugar. One feeding of this is substituted for a 
protein milk feeding, then, if no bad results occur, the protein 
milk feedings are diminished, and the others increased, until 
finally the entire day's supply consists of the ordinary formula. 
If the stools remain smooth and well digested, sugar may be 
added up to 6 or 7 per cent., but in many cases it is necessary 
to continue on a rather low sugar over a considerable period of 
time. Dry milk or lactic acid milk mixtures also work very 
well in some cases. 

Chronic Starch Indigestion. — This is usually seen in older 
children, and will be discussed in another chapter. 

Marasmus (Infantile Atrophy, Athrepsia, Decomposition). 
— Definition. — ^An extreme degree of malnutrition, dependent 



276 PRACTICAL INFANT FEEDING 

upon prolonged indigestion or underfeeding. The end-result of 
long-continued indigestion, whether due to fat, starch, or sugar. 
It is of such a striking appearance, so well defined clinically, 
and the nutritional damage is so extensive, that it seems best to 
classify it as an end-result, and not to speak of it as a "chronic 
indigestion." 

Occurrence. — Marasmus is not usually seen before the second 
or third month; after this it may be seen at any time. "Chronic 
intestinal indigestion" or "intestinal infantilism" is its equivalent 
in older children. It is not nearly so common as formerly, 
because artificial feeding is so much more satisfactory than it 
used to be. It is seen especially among the poor, and represents 
one of the most common groups of cases treated in any hospital 
devoted to infants. It is not at all common in well-to-do private 
practice. 

Etiology and Pathogenesis. — If a baby has a severe chronic 
indigestion which extends over a long period of time, he does 
not absorb sufficient calories to cover his nutritional needs. 
The body fat is, therefore, drawn upon and used as fuel. When 
this is exhausted the body protein may be drawn upon to a 
certain extent. There is a continued loss of salts from the 
body in the stools, particularly if diarrhea is present, and there 
may be a negative nitrogen balance. The baby finally reaches 
a condition of "metabolic bankruptcy," as Finkelstein has said. 
Thus certain of the body cells disintegrate, and all the vital 
functions, especially that of digestion, become weakened as 
the condition progresses. There is, as Marriott^ has shown, 
an actual atrophy of the blood, due to the using up of the blood 
protein, which "leads to a diminished volume, and this, in its 
turn, to a diminished volume flow^ of the blood." This results 
in diminished oxidation of the tissues, and poor nutrition of 
€very part of the body. "It is not surprising that the intes- 
tinal tract and the digestive glands supplied by an atrophied, 

' Marriott, Notes on Infant Nutrition, 1920. 

2 The amount of blood passing through a given part of the body in a unit 
of time. 



DIGESTIVE DISTRUBANCES IN THE BOTTLE FED 277 

poorly circulating blood should be functionally inefficient, with 
the result that digestion and absorption are poor."^ Various 
observers have reported a deficiency of the digestive ferments 
as a cause of marasmus, but it is probable that this is a result 
of the condition rather than its cause. The fat-splitting ferment 
of the pancreas is particularly likely to be deficient, and the 
hydrochloric acid of the stomach may also be considerably 
diminished. 

The pathologic lesions at autopsy are insignificant, and, 
indeed, there are no distinctive or characteristic lesions. Tuber- 
culosis, syphilis, congenital atelectasis, and many other diseases 
may produce very much the same picture. The type of case 
discussed here is, however, to quote Dr. Holt, "a vice of nutri- 
tion only." 

Almost all observers have reported a diminished fat absorp- 
tion, although in most cases the fat is split as well as normally. 
The nitrogen and salt balances are likely to be negative when 
weight is being lost, but during periods of stationary weight or 
of increasing weight are positive. There may be a secondary 
relative acidosis caused by withdrawal of base from the body 
and the suboxidation brought about by the diminished volume 
flow of the blood. 

Clinical History. — ^A baby of six months is brought, who 
weighs 7 pounds. He is little more than skin and bones. He 
was breast fed for a few weeks and then nursing was discon- 
tinued because the mother's milk left her, or because she or her 
doctor "though it was too weak." The baby was then started 
on a top milk mixture containing a large amount of fat, or on 
condensed milk, or on a proprietary food formula. He did well 
for a while, and then began to have loose, undigested stools, 
and to lose weight. He was then tried on one thing after another, 
with equally bad results, and with an increasing intolerance for 
food of any sort. He may have vomited considerably; the 
stools may have been constipated, of the ''soap stool" type, if 
he has been fed on a high fat, or diarrheal and acid if he has 

* Marriott, loc. cit. 



12yS PRACTICAL INFANT FEEDING 

had an intolerance for sugar. There has been a progressive loss 
of weight, until finally an extreme stage of malnutrition is 
reached. 

Clinical Appearance. — ^The most striking thing is the extreme 
emaciation. The baby may be little more than a skeleton 
covered with skin and a little flabby muscle tissue. The face is 
very sharp and weazened, giving the characteristic "little old 
man" appearance. The flesh is extremely soft and flabby, and 
the skin hangs in inelastic loose folds. The arms and legs are 
like pipestems and the hands like the claws of a bird. There is 
practically always a secondary anemia, sometimes of a severe 
degree, and often a peculiar grayish color of the skin. The 
heart sounds are feeble and the pulse usually slow. The abdo- 
men is usually distended and the coils of the intestines may be 
seen through its thin walls, or if diarrhea has been profuse, and 
the baby is "dried out," it may be much sunken. The hands 
and feet are cold and may be cyanotic. The temperature is 
likely to be subnormal, and may sink as low as 94° or 95° F. 
The face has an anxious expression, but the mentality is usually 
alert, and the bright eyes assume an unusual prominence in the 
shrunken face. The child seems continuously hungry, and is 
very likely to suck its hands. Food is usually taken voraciously, 
but occasionally the baby will take so little that tube feeding 
has to be resorted to. 

The stools may be of almost any variety. For a while they 
may be constipated, alkaline, and somewhat foul, with a large 
insoluble soap residue, especially if the baby is fed on mixtures 
containing any but a very small quantity of fat. Diarrhea 
occurs on the slightest provocation if the food tolerance is 
overstepped, and it is during the diarrheal periods that large 
and rapid losses of weight may occur. The diarrheal stools 
may be strongly acid in character and green in color, or, again, 
may be alkaline and brown, with a foul odor. There may be 
occasionally very rapid gains in weight, which are caused by 
the development of edema, and rapid gains should, therefore, 
always be regarded somewhat skeptically. Furunculosis is 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 279 

common and often very difficult to get rid of. In a hospital 
ward one of the greatest problems is to prevent the development 
of upper respiratory infection, and otitis media, bronchitis, and 
bronchopneumonia are very common. It is these upper respira- 
tory infections which largely accoimt for the high mortality in 
marasmic infants. 

If excessive intestinal fermentation occurs there may be a 
rapid development of toxic symptoms, in which case the baby 
becomes very apathetic and drowsy, and we have added to the 
condition of marasmus one of intoxication. 

Treatment is most difficult, and taxes to the utmost the 
resources of the art of infant feeding. 

In any severe case of marasmus a wet-nurse should be 
secured if possible, and in many cases success will not follow 
without one. In most of the ordinary ' 'feeding cases" encoun- 
tered wet-nurses are not now-a-days necessary, on accoimt of 
the fact that our knowledge of artificial feeding is so much 
better than it was in years gone by. But in marasmus the 
nutritional damage has proceeded so far that nothing can serve 
so well as human milk. 

Wet-nurses are a problem. In the present day so many 
people live in small apartments that there is not room in the 
household for a wet-nurse, to say nothing of her baby, which 
has to go with her. Wet-nurses and their babies do not fit well 
in small households. Still, if it is a question of saving a life, 
arrangements may be made, and if the situation is carefully 
explained to the family, they are willing to put up with the 
oftentimes severe inconvenience and heavy expense. In large 
households where a wet-nurse could be easily cared for and paid 
marasmus does not occur, and it is the poor, who are unable 
to care for wet-nurses, who need them most. It is often possible 
for the mother to find some nearby friend with a nursing baby 
who will come in two or three times a day and give a nursing, 
or who will pump her breasts and send a few ounces of milk a 
day. This is decidedly worth while, as even a small amount of 
breast milk may serve to swing the balance in the baby's favor. 



28o PRACTICAL INFANT FEEDING 

Even with breast milk considerable caution must be used, 
and the baby should never be put to the breast for a full nursing 
in the beginning. For the first few days not more than 10 or 
12 ounces a day should be allowed, making up the balance with 
water. It is usually best to let the baby take only the first part 
of the nursing (the "fore-milk"), so that he will not get the 
"strippings" or last part of the milk, which is rich in fat. 
Sometimes the fat tolerance, even for breast-milk fat, is so poor 
that it is necessary to pump the breast milk, to "set" it for six 
hours or more, and then to skim the cream off, giving the baby 
a nearly fat-free milk. Even with breast feeding good results 
do not always occur at once. The baby must be underfed at 
first, as if enough food is given to supply his caloric needs it is 
likely to upset him, so gain in weight cannot be expected for 
some time. Breast feeding should not be given up, therefore, 
simply because the baby does not gain for a week or two, or 
because the breast milk does not seem to "agree with him." 
As the general condition begins to improve, and his food tol- 
erance increases, he may be allowed to nurse longer, until 
finally he is taking the full nursing. When breast feeding is 
discontinued it should not be done abruptly, but one or two 
feedings of a rather weak modification should be substituted 
for an equal number of breast feedings, until the baby is grad- 
ually fed entirely on the bottle. 

Artificial Feeding. — Reduced to its simplest terms, we are 
confronted with the following problem: 

We have a baby whose caloric needs are much higher than 
those of a normal baby of the same weight, but whose food toler- 
ance is so low that it is not possible to meet these caloric needs and 
to bring about a gain in weight without producing a severe digestive 
upset. The slightest overstepping of the food tolerance may 
result in a severe diarrhea with a marked loss in weight. The 
general principle of treatment is, then, to begin with a very 
weak food, entirely irrespective of caloric requirements, and to 
gradually increase it, not expecting a gain in weight for some 
time. 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 281 

If the stools are loose and undigested the first essential, the 
first stage in the treatment, the "reparation" stage, so-called, 
is to stop the diarrhea, and to feed such a food as will cause the 
movements to become smooth and infrequent. No baby can 
go ahead, and will almost certainly go backward, if diarrhea is 
present. The diarrhea cannot, however, be treated in just the 
same way that it might be in a more normal baby, as marasmic 
infants bear starvation very poorly. It is never well to starve 
them even to clear up a diarrhea. 

The following three general principles hold for most cases: 

1. Fat is handled very poorly, and any formula that is used, 
except perhaps protein milk, should contain very little fat. 

2. It is desirable to get as much sugar into the baby as 
possible. If the sugar tolerance is good, as it is in many cases, 
the treatment is vastly simplified, as it is possible by the use of 
a high percentage of sugar to furnish many extra calories. 
The sugar tolerance may be poor, however. 

3. Protein is handled better than either of the other food 
elements, and it is upon mixtures high in protein that we usually 
rely. 

Details. — In a case with loose movements, protein milk, 
dried milk, or boiled skimmed milk mixtures are the most reliable 
preparations to begin with. To the first about 3 per cent, of 
dextrimaltose should be added, with the last two no sugar 
should be used in the beginning. 

The feedings should be very small to begin with and at 
frequent intervals, usually every two hours. In an average 
case not more than 1 ounce of protein milk should be used at a 
feeding, the balance of the feeding being made up with water 
in amoimts to correspond with the age and size of the child, in 
order to supply the fluid needs of the body. As the stools im- 
prove the intervals may be lengthened to 2J or three hours, 
and the amount at each feeding increased. When the stools 
have become smooth and salve-like, carbohydrate, in the form 
of dextrimaltose, may be gradually added up to the limit of 
tolerance. 



282 PRACTICAL INFANT FEEDING 

If dried milk is used it is well to begin with not more than 
one-third strength, that is, about 2^ level tablespoons of Dryco 
dried milk to 8 ounces of water. This gives a very weak food, 
containing practically no fat, and a relatively high percentage of 
protein in an easily assimilable form. As the stools improve 
this can be very gradually increased up to the full strength, that 
is, 8 level tablespoons to 8 ounces of water, which gives 1.5 per 
cent fat, 5.5 per cent, sugar, 4.2 per cent, protein. If the stools 
remain smooth and apparently well digested, and the baby is 
not gaining weight, more sugar may be added, up to the limit 
of sugar tolerance. If skimmed milk is used, the initial formula 
should be usually one-half milk, one-half water or barley-water, 
giving percentages of fat 0, sugar 2.25, protein 1.60. It should 
always be boiled in order to insure a soft casein curd, and it is 
often possible to give high concentrations of skimmed milk in 
this form. In some cases it is possible after a while to use 
undiluted boiled skimmed milk, and often considerable sugar 
may be added without symptoms of intolerance. It is always 
advisable to use a centrifuged fat-free milk if possible, as with 
the ordinary methods of skimming there is always some fat 
left, which is likely not to be tolerated. 

In cases with constipated stools it is best to begin with 
ordinary mUk mixtures (boiled) containing no fat, a fairly high 
carbohydrate (6 to 7 per cent.), and a moderate protein per- 
centage (1.50 per cent.). If the sugar tolerance is good, as it 
well may be in constipated cases, with alkaline stools, it may be 
possible to increase the carbohydrate to 8 or 10 per cent., or 
even more, provided no fat is given. Keller's malt soup, con- 
taining 12 per cent, of carbohydrate in various forms (see 
Chapter IX), works very well in some cases. Fat can be grad* 
ually added, | per cent, at a time, as the baby begins to get 
stronger and generally better. The stools should be examined 
microscopically every few days, and if large amounts of fat are 
coming through it is well to reduce the amount of fat in the food 
even if there are no symptoms, as a fat ''blow up" with diarrhea 
and loss of weight may occur suddenly and without warning. 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 283 

Condensed milk is sometimes of value to tide over a difficult 
stage, especially when the stomach is intolerant. Condensed 
milk is a very weak food, very high in carbohydrate, and low 
in fat and protein, and is not suitable as a permanent food, but 
is so easily assimilable that in a few cases it will be kept down 
when nothing else will. In cases with diarrhea it should not be 
used, as it is too high in carbohydrate. Fat-free lactic acid milk 
and corn syrup mixtures, as advocated by Marriott, are often 
very successful. If fat-free lactic acid milk is diluted one-half 
with water the percentages are fat 0, sugar 2, protein 1.75. 
Corn S3n:up may be added to this mixture, sometimes in large 
amounts, and it may be possible to introduce many sugar 
calories in this form without causing diarrhea. If 45 c.c. of corn 
syrup and 55 c.c. of water are mixed, the resulting 100 c.c. of 
mixture contains about 50 grams of carbohydrate, consisting of 
maltose, dextrins, and dextrose; 10 c.c. of this, added to a 
4-ounce feeding, increases the sugar percentage a Kttle over 
4 per cent. In some cases Marriott^ was able to use as much 
as 12 or 14 per cent, of carbohydrate in this medium, with very 
good results, and undoubtedly it is often possible to use a higher 
carbohydrate in a protein milk or lactic acid milk mixture than 
in any other way. I have had personally very little experience 
with this method of feeding, but it would seem to be a very 
valuable addition to our armamentarium in treating marasmic 
babies. 

Homogenized olive oil mixtures are sometimes useful, and it 
may be possible to use 2 or 3 per cent, of fat in this form when 
no butter fat can be tolerated. 

Warmth. — The marasmic baby has practically no fat tissue 
to prevent the loss of heat from his body; his surface area is 
large in proportion to his mass; therefore he loses heat readily, 
and may be put into the same category as the premature in 
this respect. It is absolutely essential to keep him warm, and 
it may be necessary in very bad cases to wrap the child in a 
jacket in the same way that a premature would be cared for. 

1 Loc. cit. 



284 PRACTICAL INFANT FEEDING 

The temperature is just as important to watch as the weight, 
and if it is subnormal, hot- water bottles should be kept con- 
tinually in the bed. Dr. W. W. Howell, of the Infant's Hospital, 
has some rather remarkable charts, showing the effect of the 
temperature at which the marasmic baby is kept, on the gain in 
weight. Many times he has moved marasmic babies back and 
forth from the regular ward of the hospital to the hot room 
(kept at 80° F.), and his charts show without question that gain 
in weight is much more rapid and more certain in most cases 
when the temperature is kept between 75° and 80° F. than at 
the ordinary ward figure. These facts should always be borne 
in mind when dealing with a marasmic baby, and a brief chilling 
may mean all the difference between life and death. 

Drugs are of secondary importance, but may help some- 
times in tiding over difficult periods. 

The artificial digestants are of little value, and are not used 
by most men who are familiar with marasmus. Precipitated 
chalk in \ teaspoonful doses to each feeding may help to control 
a diarrhea if the stools are excessively acid. The stimulants 
that have been used are brandy, adrenalin, caffein, and cam- 
phor. Of these, brandy is probably the best, and small doses 
of it may be sometimes useful to tide over a critical stage. 
The effect of adrenalin is powerful in collapse, but is very 
transitory. Caffein and camphor may be of use if the heart 
action is weak. As a general thing drug stimulation is of sec- 
ondary importance; what a marasmic baby needs is to have its 
body cells dJasoihJood and fluid. 

Subcutaneous and intravenous injections of normal saline or of 
glucose may accomplish a great deal in some cases. For a dis- 
cussion of the technic and indications see the chapter on Diarrhea. 

Course. — ^The baby will not begin to gain weight until his 
caloric needs are well covered, which in many cases will not be 
for some time. If he is not vomiting, if his stools are good, if 
his general condition is better, and he is not losing weight, it is 
well to be satisfied for a time before increasing the diet. As 
we have said before, theoretic caloric requirements are often 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 285 

of little value as a practical guide for feeding, but as a general 
rule marasmic babies will not begin to gain until they are getting 
at least 60 calories per pound, and often need more than this. 
If the sugar tolerance is good, it is often possible to feed a high 
caloric diet without much risk of an upset. Relapses almost 
always occur, brought about sometimes by overfeeding, some- 
times from the influence of intercurrent infections. During a 
relapse the stools become loose and frequent, the color of the 
baby bad, the temperature either subnormal or elevated, and 
the weight sinks very rapidly. In some cases there may be 
evidences of extreme intoxication, as evidenced by somnolence, 
hyperpnea, and collapse. During periods of diarrhea it is never 
well to starve the baby, as we might do with a normal baby, as 
marasmic cases bear starvation very poorly, and are likely to 
die from it. The food should, however, be somewhat reduced 
in strength, and if a high sugar has been used, and the stools 
are acid in character, it is best to shift to a low sugar and rela- 
tively high protein; if a high protein feeding has been used, one 
would shift to a low protein and relatively high sugar. 

It is of great importance during periods of diarrhea or during 
times when the baby is not eating well to keep up the fluid 
intake, and for this purpose normal saline should be given sub- 
cutaneously or glucose solutions intravenously. One of the 
worst things that can happen to a marasmic baby is to get 
"dried out,'' and the fluid intake should always be regulated 
as carefully as the fat, carbohydrate, and protein. Even under 
the best conditions treatment is long drawn out, and many 
discouragements will have to be met before the baby goes ahead 
steadily. In many cases no food, no matter what is tried, 
seems to be able to bring about an increase in weight; then 
often, after several weeks of careful dieting, the baby will shoot 
ahead all of a sudden, and continue to do well, upon some food 
which before failed to cause him to gain. It would seem as 
though a period of freedom from intestinal irritation were 
necessary before the intestine is able to absorb enough food in 
order to bring about an increase of weight. As a general thing 



286 PRACTICAL INFANT FEEDING 

marasmic babies do better at home than in a hospital, provided 
the home is a good one, largely because the risk of infection is 
much less, and they are likely to get more individual attention. 
Prognosis. — Doubtful always. The baby may be apparently 
doing well, then may pick up some seemingly trivial naso- 
pharyngeal infection, develop a bronchitis or a bronchopneu- 
monia, and die from it. Or sudden collapse and death may 
occur without apparent reason. In the very worst cases the 
chances of recovery with artificial feeding are always bad, and 
these cases must have breast milk or die. The average case 
ought to recover with intelligent artificial feeding, although it 
may be a good many weeks before much weight is gained. 
When once the baby starts to gain, progress may be rapid, and 
a case of this sort that is doing well is indeed a satisfaction. 
The younger the baby, the worse the prognosis, as a general 
thing. The cases due to underfeeding and neglect are likely to 
respond better than those due to long-continued indigestion. 
When once the nutritional damage has been repaired, and the 
child is of normal weight for its age, the chances are that he will 
be as healthy as any other child. 

A FEW GENERAL SUGGESTIONS FOR DIFFICULT FEEDING CASES 

1. A careful history is of great importance; it shows what 
has been well borne in the past and what has not, and gives 
valuable suggestions as to what to avoid. The last man who 
gets one of the difficult feeding cases which have been the 
rounds of several pediatrists is the one who is most likely to 
succeed with it, as he profits by the experience of his brother 
practitioners. 

2. It is always a good idea on beginning with a difficult case 
to tell the mother that ''Rome was not built in a day" and that 
a malnourished baby cannot be made fat over night — but that 
if she will be patient, good results are sure to be secured in the 
long run. 

3. In any case with undigested, loose movements, the move- 
ments must be made smooth and of normal consistency before 



DIGESTIVE DISTURBANCES IN THE BOTTLE FED 287 

satisfactory progress as to weight can be expected. This is the 
first stage in the treatment of most cases. 

4. It is not well to be too eager for rapid and large gains in 
weight. Be satisfied with a few ounces a week for a few weeks 
if the baby is eating well, feeling well, and having good stools. 

5. It is a mistake to change formulae too quickly. Give the 
baby a good try-out of several days on a formula before deciding 
that it does not agree with him. 

6. If more than one element is increased at a time it is very 
difficult to tell what has upset the baby, if upset occurs. 

7. Theoretic caloric requireraents are of very little practical 
value — feed the baby all he will stand, irrespective of calories. 

8. Use as high a sugar as is possible without causing fermen- 
tation. If the stools are not loose the baby can probably take 
a great deal of it without being upset, and the more sugar he 
can absorb, the more weight he will gain. 

9. Never forget that the high protein, low sugar principle 
(protein milk, etc.) is the most efficient way of stopping abnor- 
mal intestinal fermentation. 

10. Malt sugar preparations are by no means always a cure 
for sugar troubles. In some babies they ferment as easily as 
lactose. 

11. Loss of appetite is one of the most common symptoms of 
beginning fat indigestion. 

12. Remember that starch is not used as much as it should 
be in difficult feeding cases. Some babies improve remarkably 
as soon as a little starch is added to the formula. 

13. Have always a definite plan of campaign in every case, 
and stick to it. 

14. The proprietary foods can contain nothing that your 
own milk modifications cannot contain. 

15. The more one knows about the chemistry of digestion 
and its abnormalities, the processes that are going on in the 
bowel, the more likely is he to get good results. One would not 
consider that he had an adequate idea of a disease such as 
pneumonia without knowing something of its pathology. It is 



288 PRACTICAL INFANT FEEDING 

just as necessary to have a knowledge of digestive pathology in 
order to feed infants successfully. The reason why so many 
practitioners get poor results in infant feeding is that they have 
no knowledge whatever of the processes that are going on inside 
the baby; they try this and that formula or preparation, without 
knowing why. Ask yourself why for every formula you use and 
every change you make. 



CHAPTER XI 
IDIOSYNCRASY TO COWS MILK 

Most babies who are supposed by the mother to have an 
idiosyncrasy to cow^s milk are not suffering from any specific 
idiosyncrasy, but their symptoms are caused by improper 
modifications of milk, and can usually be corrected with proper 
feeding. There are cases, however, not so very uncommon, of 
true anaphylactic idiosyncrasy to cow's milk protein, and in 
some instances ingestion of even a few drops of milk may bring 
about alarming symptoms. Within a few minutes the lips, 
tongue, and buccal mucous membrane swell, and there may be 
symptoms of collapse. These symptoms usually disappear in 
an hour or two, and are likely to be followed by urticaria, which 
may last about twenty-four hours. ^ In other cases, the idiosjrn- 
crasy may be manifested by asthmatic attacks, following soon 
after the ingestion of milk, or by eczema. Again, there may be 
vomiting and drowsiness, which may not come on for two or 
three hours after the milk has been taken, as in Park's case,^ or 
severe sudden diarrhea. There is almost always some skin 
manifestation, such as urticaria or angioneurotic edema, and in 
2 cases of milk idiosyncrasy that I have had recently in my own 
practice, one was manifested only by a very extensive skin 
eruption resembling erythema multiforme, the other by extreme 
swelling of the lips and cheeks. In mild cases there may be little 
systemic disturbance, and the manifestations may be confined 
entirely to the skin. In the severe cases the symptoms may be 
very alarming and may threaten life, although I have been 
able to find no report of any case which has died. The idiosyn- 

1 Schloss, Amer. Jour. Dis. Chil., vol. 19, 1920. 
2Amer. Jour. Dis. Chil., vol. 19, 1920. 
X9 289 



290 PRACTICAL INFANT FEEDING 

crasy may exist from birth or may be acquired. Park's case 
was only six weeks old, and had never received cow's milk before, 
as far as was known. The condition is most likely to be seen in 
somewhat older babies when they are weaned, the S5miptoms 
usually making their appearance the first time cow's milk is 
taken. 

Diagnosis. — ^The diagnosis is simple and depends upon cause 
and effect, the cause being the taking of cow's milk, the effect, 
the symptoms which soon follow. In most cases the symptoms 
follow so soon upon the taking of milk that the mother makes 
the diagnosis. As we have said, the trouble has to do only with 
the protein of the milk, and the sensitization may be either 
to casein or to lactalbumin, most commonly to the latter. In 
only 2 out of Schloss's 14 cases of milk idiosyncrasy did casein 
cause a skin reaction, and then to a much less marked degree 
than lactalbmnin. It is important to determine to which of 
these proteins the anaphylactic phenomena are due, as treat- 
ment is sometimes planned accordingly. In a great many cases 
the skin tests will indicate this. These are very simple to do, 
and purified powdered proteins from all sorts of foods are on 
the market.^ Three scratches about J inch long are made with 
a needle into the skin of the back,^ and a small quantity of the 
powdered lactalbumin and casein placed on two of the scratches, 
the third being left for a control. Then a drop of N/10 sodium 
hydrate is added from a medicine-dropper and is mixed with 
the protein. If the test is negative there is no difference between 
the control and the scratches to which protein has been added. 
If the test is positive, in about &ve minutes an urticarial wheal 
appears, which is surrounded by a red areola. It has been said 
that a wheal to be positive must measure at least | cm., and that 
all reactions of this size should be considered positive. It is 
probably better, however, to use the control as a standard, and 
if the protein being tested gives a wheal which is noticeably 

^ Arlington Chemical Co., Yonkers, N. Y. 

2 The arm is the place ordinarily used, but we have found at the Chil- 
dren's Hospital that in dealing with babies the back is more convenient. 



IDIOSYNCRASY TO COW's MILK 29I 

larger than that caused by the control scratch, it is better to call 
it positive, no matter how large or how small it may be. 

A negative skin test is not at all reliable, and a good many 
cases of milk idiosyncrasy will show negative tests both to 
casein and to lactalbumin, as after an attack of anaphylaxis 
there may be often a period of anti-anaphylaxis, when the 
patient is not sensitized, which may last for several days or 
weeks. Schloss^ has reported 5 cases of undoubted idiosyncrasy 
to cow's milk, with persistently negative skin tests. 

Treatment. — Certain cases may be able to take without 
disturbance dried milk, evaporated milk, or milk which has 
been vigorously boiled. This difference is probably due to some 
change produced in the protein by heating. It is worth while in 
cases of moderate severity to try one or all of these methods; 
but if the idiosyncrasy still persists the method of treatment is 
to feed the infant upon goat's milk, as in practically all these 
cases there is no idiosyncrasy to goat casein or lactalbumin. If 
the baby is not too old, and it is easier to get a wet-nurse than a 
goat, this method of feeding is satisfactory. If the family lives 
in the country a goat can be easily obtained and kept; if they 
live in the city this is usually out of the question, but often 
arrangements may be made with a miUonan to get a goat, and 
deliver the milk daily. 

Another more satisfactory and simple way of using goat's 
milk is in the evaporated form, and a very satisfactory evapor- 
ated goat's milk may be obtained, which is often truly a godsend 
to a family living in the city. (For details of evaporated goat's 
milk see Chapter VIII.) I fed one baby with severe cow's milk 
idiosyncrasy on evaporated goat's milk for over six months, 
with very good results. In severe cases goat's milk or human 
milk is necessary, but in mild cases it is often possible, provided 
it is known whether the offending substance is lactalbumin or 
casein, to make up a milk modification containing so little of it 
that no symptoms result. If the idiosyncrasy is for lactalbumin 
a precipitated casein mixture may be employed, and if a heavy 

1 Loc. cit. 



292 PRACTICAL INFANT FEEDING 

cream is used the mixture will contain very little lactalbimiin.* 
If the idiosyncrasy is for casein, a whey mixture is indicated. 
It is usually best, however, to turn to goat's milk, as these mix- 
tures may not be suitable for administration over a long period 
of time. They may do, however, to tide over while the goat is 
being found or while the evaporated milk is being obtained. 
It is well in all these cases to begin solid food as early as possi- 
ble, and cereals, spinach, and beef juice may be started in small 
amounts at the seventh or eighth month. Olive oil may also be 
of value in some cases. 

Desensitization. — ^A good many cases become desensitized 
spontaneously, and may be able after a few months of feeding 
with the goat milk to take cow^s milk with impunity. Or they 
may be desensitized by administering very small and gradually 
increasing amounts of cow's milk. It may be necessary in 
severe cases to use very small amounts of cow's milk, sometimes 
as little as ^5 drop of milk three times a day to begin with 
(Schloss). It is usually safe to start with a drop three times a 
day, and to increase this dosage day by day if no symptoms 
occur. The results are likely to be good, and desensitization can 
usually be accomplished in a few months. Milk idiosyncrasy is 
not likely to persist into childhood, although some children who 
have had a milk idiosyncrasy are never very fond of milk, and 
cannot be made to take much of it. 

* Or the milk may be boiled and the scum on the surface, which consists 
largely of coagulated lactalbumin, removed by skimming. 



CHAPTER XII 

THE DIARRHEAL DISEASES^ 

The diarrheal diseases, often spoken of collectively as "sum- 
mer diarrhea," undoubtedly kill more babies than any other 
one cause. These diseases are largely preventable, and in most 
cases respond to proper therapy, whereas many improperly 
treated cases die, often on account of poor treatment. It is, 
therefore, essential for all physicians dealing with children to 
have as clear an idea as possible of these conditions. The diar- 
rheal diseases have always interested pediatrists, and in going 
over the literature I was so struck by the confusion that exists 
in the nomenclature, classification and treatment, and by the 
opposing views held by many authorities, that I have purposely 
left out all references, argimients, and contradictory opinions 
from this chapter, and have written in a dogmatic manner, 
which is probably not justified, but which will undoubtedly 
give to the reader a clearer conception of the diarrheal diseases 
than would otherwise be the case. The diarrheal diseases occur 
chiefly in the summer and bear a definite relationship to hot 
weather. In the South they begin to appear about the middle 
of May; in Boston, usually not until the first part of July. They 
are especially common during muggy weather. They attack 
chiefly bottle-fed infants up to two years of age, largely of the 
poorer class. 

Any diarrhea is caused by increased intestinal peristalsis^ 
This increased peristalsis is caused by some irritant acting on 
the intestinal mucous membrane, and it is best to classify diar- 
rheal conditions according to the t3^e of irritant that is causing 

1 Much of this chapter appeared in the Journal of the American Medical- 
Association for June 7, 1919, and I am indebted to the editors for permission 
to use it again. 

293 



294 PRACTICAL INFANT FEEDING 

the trouble. Broadly speaking, the diarrheal diseases of infancy 
may be divided into three groups: 

1. Mechanical diarrhea, due to mechanical irritation. 

2. Fermentative diarrhea, due to chemical irritation. 

3. Infectious diarrhea, due to bacterial irritation. 

In the first group the irritation is mechanical, and is caused 
by undigested pieces of food, or by such things as unripe fruit, 
seeds, or skins. In the second group the trouble is caused by 
irritating products from bacterial fermentation or putrefaction 
of food in the intestine, brought about in several different ways, 
as we shall see later. There is no infection by bacteria of the 
intestinal mucous membrane in this condition; it is the intes- 
tinal contents which are infected. In the third group there is 
actual invasion of the intestinal mucosa by bacteria, with 
catarrhal inflanunation, or often actual ulceration. 

This is an exceedingly simple and in most cases a satisfactory 
classification. It must be remembered, however, that the lines 
between the three groups are not always hard and fast, for 
these reasons: 

1. With any diarrhea there is always some fermentation, 
even if the primary cause be infectious or mechanical. 

2. In infectious diarrhea in most cases the trouble is caused 
by a direct infection per os of the previously healthy intestinal 
mucosa, with virulent pathogenic bacteria (dysentery, strep- 
tococcus) introduced from without. This is not, however, 
always the case, and if the mucosa of the bowel is first injured 
or irritated by chemical or mechanical agencies, bacteria (colon 
bacilli, gas bacilli, dysentery), normally Living a more or less 
saprophytic existence in the intestine, may be able to get a 
foothold in the irritated places, and thus infect the previously 
irritated mucosa, when they would be powerless against it if it 
were uninjured. Thus it is frequent for mechanical or chemical 
agencies to bring about a true infectious diarrhea in an indirect 
way. The distinctions between the three groups are, in the main, 
however, fairly clear cut. 

It is of great practical importance to bear in mind these dis- 



THE DIARRHEAL DISEASES 295 

tinctions, as the feeding for the different sorts of diarrhea may 
be entirely different; what is proper for an infectious case might 
be fatal in a fermentative one. I cannot emphasize too strongly 
that not all infantile diarrheas are the same, and that they should 
not all be treated in the same routine manner. The first essen- 
tial is a correct diagnosis, and in order to arrive at this the 
etiology of the three groupings must be thoroughly understood. 

MECHANICAL DIARRHEA 

This type of diarrhea is fairly common, and is more likely 
to be seen in children above the age of one year than in those 
younger. It is caused by mechanical irritation of the dehcate 
intestinal mucosa from such things as grape skins, cucumbers, 
and raw fruit. It is a common practice among many ignorant 
people to feed all sorts of indigestible foods, particularly raw 
fruit, to small children from one to five years of age long before 
they are ready for it. Some children seem to be able to stand 
this, but the majority cannot, and no raw fruits should be fed to 
any child under five years old. In many cases the mechanical 
irritation of the intestine paves the way for organisms to attack 
it in the irritated places, so that often a mechanical diarrhea 
may change to one of the true infectious type. A typical case 
of mechanical diarrhea would run about as foUows: A child of 
two is given a peach to eat, skin and all. The peach may be 
ripe or it may not be. Soon after the child is taken severely 
sick, with vomiting and diarrhea. The stools are usually five 
or six in the twenty-four hours, and are likely to contain undi- 
gested peach pulp and skin. The vomiting may be so severe as 
to be uncontrollable, and it is in this type of diarrhea that 
gastric disturbance is most common. In some cases there may 
be a tremendous amount of toxemia, and not infrequently these 
children die, partly from acidosis caused by the severe vomiting 
and partly probably from the absorption into the circulation 
through the injured intestinal wall of toxic material or possibly 
bacteria from the intestine. Every practitioner of experience 
has seen cases such as this. Last summer I saw a boy of six at 



296 PRACTICAL INFANT FEEDING 

the Children's Hospital who died in forty-eight hours from 
eating a raw cucumber. In ordinary cases the child will be well 
in two or three days, and the diagnosis and treatment offer no 
difficulty save in those cases which develop infectious diarrhea. 
The treatment consists simply in purging the child with 
castor oil or calomel, putting him to bed, giving him barley- 
water or some other gruel for twelve hours, with plenty of water, 
and then starting him on a bland, non-irritating diet of cereal 
and boiled skimmed milk. This is the simplest and least impor- 
tant of the infantile diarrheas. 

FERMENTATIVE DIARRHEA 

This is a more complicated and important condition, and is 
the most common diarrhea of babies. It is most likely to occur 
in children under one year, but may be seen at any age. It is 
brought about by abnormal decomposition of food in the intes- 
tine, caused either by the bacteria which are already there or 
by bacteria introduced from without. The products of fermen- 
tation irritate the intestinal mucosa and cause a diarrhea, but 
the mucous membrane is not attacked by bacteria. The 
abnormal decomposition is usually that of sugar, and may be 
caused in several ways. In order for sugar fermentation to 
occur two conditions must exist: unabsorbed sugar in the 
intestine and bacteria in the same portion of the intestine to 
attack it. Under normal conditions the small intestine is 
relatively sterile, the large intestine is swarming with bacteria. 
Therefore, any conditions that allow a considerable amount of 
undigested sugar to proceed lower than is normal in the digestive 
tract, or which will allow bacteria to flourish in the small intes- 
tine, where there is always unabsorbed sugar, will bring about 
sugar fermentation. Let us consider some of these conditions. 

Overfeeding with Sugar. — If too high a percentage of sugar, 
or if too much food, thus giving a large amount of sugar, is fed 
to a baby, all of the sugar cannot be absorbed. What is not 
absorbed passes into the lower part of the intestine and the ever- 
ready bacteria there attack it and ferment it. 



THE DIARRHEAL DISEASES 297 

"Parenteral" Infections. — It is well known by every practi- 
tioner that babies suffering from such affections as rhinitis, 
bronchitis, or otitis media are likely to have loose, greenish 
stools. The probable reason for this is that in these conditions 
the digestive juices are reduced in amount, so that sugar is not 
digested so well as normally and thus is fermented; or that under 
the general debilitating influence of any extra intestinal disease 
the intestinal mucous membrane loses some of its antibacterial 
power and thus allows bacteria to flourish higher in the intestine 
than they would normally. 

Overheating of the body is an important cause of sugar 
fermentation. This is well known clinically and has also been 
proved by animal experimentation. The practice of dressing 
babies too warm in hot weather is undoubtedly the cause of a 
good many cases of sugar diarrhea. The explanation of this is 
probably very similar to that for "parenteral" diarrhea. Owing 
to the debilitating heat, the digestive juices are lessened in 
amount, and the efflciency of the mucous membrane is impaired 
in such a way that undigested sugar is permitted to pass down 
where bacteria can get at it, or the bacteria are allowed to come 
up and flourish where the sugar is. 

Nervous Exhaustion and Excitement. — ^These may bring 
about sugar fermentation, probably in a way similar to that in 
which it is brought about in the last two conditions I have 
discussed. However, it is not a particularly frequent or impor- 
tant cause of sugar fermentation. 

Constitutional Weakness. — There are certain babies who, on 
account of constitutional weakness, never seem to be able to 
take much sugar, or, indeed, much food of any sort without 
diarihea. It is probable that their digestive juices are ineffi- 
cient, and that there is always a great deal more bacterial 
growth in the small intestine than there should be. 

Infected Milk. — ^The types of sugar fermentation enumerated 
above are all brought about by the normal intestinal bacteria's 
taking advantage of the abnormal conditions of the host. The 
next and by far the most important type of sugar fermentation 



298 PRACTICAL INFANT FEEDING 

is caused by abnormal bacteria introduced from without in bad 
milk. Bad milk is probably the most potent source of sugar 
fermentation, and gives rise to the most severe cases of diarrhea. 
There is probably no specific organism that accomplishes this, 
although investigators have tried at various times to look on the 
condition as a specific infection. A great many different sorts 
of bacteria, when introduced into the small intestine, may 
bring it about, and probably two of the most common offenders 
are the Bacillus aerogenes capsulatus (gas bacillus) and the 
colon bacillus. 

The foregoing will serve to show the main causes of sugar 
fermentation; let us now see what chemical processes are in- 
volved. When sugar is fermented by bacteria, acids are formed. 
These may be divided into two groups: the volatile acids, such 
as formic, acetic, and butyric, and the non-volatile acids, such 
as lactic and succinic. The volatile acids particularly are formed 
in large amounts, and are the ones which do the most harm. 
The non-volatile acids are relatively harmless. It is surprising 
to see how much free acetic acid may be recovered from the 
stools of some babies with sugar fermentation, and when one 
takes into account its extremely irritating nature it is easy 
to see how much damage may be done. The volatile acids 
cause harm (1) by increasing peristalsis and causing a diarrhea 
by irritating the intestinal mucosa; (2) by injuring the mucosa 
in such a way that its antibacterial function is impaired, or to 
such an extent as to allow toxic material from the intestine to 
pass through into the general circulation, a thing which would 
never happen normally; (3) by drawing on the alkali reserve of 
the body in an attempt to neutralize the excessive acidity, thus 
probably helping to cause an acidosis; and (4) by upsetting the 
normal chemical processes of digestion, most of which cannot go 
on satisfactorily in an excessively acid intestine. 

Degrees of Sugar Fermentation. — Sugar fermentation may 
occur in three degrees of severity, which vary a good deal in 
their chemical conditions and clinical appearance: 

1. The condition may be of a very mild type, in which a 



THE DIARRHEAL DISEASES 299 

normal baby has two or three very acid stools a day of a con- 
sistency rather looser than normal. These stools may be of 
the normal color, or slightly greenish, with usually only a little 
mucus. The baby is not sick, the condition is a very mild one, 
and almost always clears up readily with proper treatment. 
Its importance lies in the fact that untreated, the condition 
may become severe, and may ultimately lead to most serious 
results. This may be seen at any time of year and probably 
has nothing to do with bad milk (cf. Sugar Indigestion). 

2. It may be a more severe condition, usually seen in the 
summer during a "muggy spell," but may occur at any time. 
The baby will have from five to ten very loose, green, acid 
stools a day, containing a good deal of mucus, and many small 
soft curds of undigested milk. The stools may contain a few 
flecks of bright blood, but this is not usually large in amount, 
and does not persist for more than a few days at the most. He 
is fussy and irritable, but is not very sick in most cases. His 
buttocks are likely to be red and excoriated from the excess of 
acid in his stools. The temperature is usually from 99.5° to 
101° F. In this section of the country, at any rate, this type 
of diarrhea is caused more often by bad milk than in any other 
way. In other sections where all milk fed to babies is boiled as 
a routine, it liiay be more often caused by some of the other 
agencies already eniunerated. The condition is a local intestinal 
one; the intestine has been irritated, the processes of digestion 
have been disturbed, but the baby's body chemistry as a whole 
has not been upset. The process has as yet caused no trouble 
further than in its original locus, the intestine. If the patient is 
properly treated, the disease should be arrested without diffi- 
culty; improperly treated or neglected, the baby may pass over 
into the state which I shall call Stage 3, a much more serious 
condition ("alimentary intoxication")- 

3. In this case the baby is very sick. He usually has a 
high temperature, but in certain cases he may be so prostrated 
that the temperature is subnormal. The fontanel, abdomen, 
and eyes are sunken, the skin hangs loosely on the flesh, and has 



300 PRACTICAL INFANT FEEDING 

lost its elasticity — all from a loss of water. There is a profuse 
watery diarrhea, ten to twenty stools in the twenty-four hours. 
The baby takes no interest in his surroundings, his mentality is 
very dull, and he may be roused with difficulty. The breathing 
is deep and sighing (hyperpnea) and the urine may show sugar 
and casts. This is the picture of "alimentary intoxication," 
and a most precarious and serious condition it is. Here the 
process originally starting as a local intestinal condition has 
progressed so that it has changed the general metabolism, and 
has perverted the chemistry of the entire body. There is a 
negative nitrogen and salt balance, there is loss of a large 
amount of fluid, very often severe acidosis, and last, but not 
least, it is probable that many injurious substances from the 
intestine are absorbed into the general circulation through the 
injured intestinal mucosa, thus adding to the severity of the 
condition. 

Treatment in Very Mild Cases. — Many normal babies are 
likely to have periods of mild sugar fermentation occasionally. 
In nearly all the following simple treatment will clear the con- 
dition up, often in twenty-four hours, and will prevent the 
development of a severe sugar fermentation. A purge is not 
necessary unless the baby has fever, and this is uncommon. All 
sugar should be omitted from the milk modification, and the 
solution boiled for three minutes; i teaspoonful of precipitated 
chalk should be added to each bottle. 

Usually after twelve or twenty-four hours of this feeding the 
stools will return to normal, when sugar can be added gradually, 
and in two or three days the baby will be back on his regular 
modification. 

Treatment in the More Severe Cases. — Groups 2 and 3 may 
be considered together in the discussion of treatment. 

Purgation. — It is a mistake to give a purge as a routine in 
every diarrheal disease. If there is any harmful material in 
the intestine which is not coming out as fast as it should, a purge 
ought to be given — otherwise not. It is not rational to purge a 
baby who is already having a great many loose stools a day 



THE DIARRHEAL DISEASES 3OI 

and whose intestine is emptying itself of toxic material as fast 
as it possibly can. In such cases castor oil or calomel adds 
insult to injury. On the other hand, a baby who is seen at the 
onset, who has fever, and who has not as yet been emptied by 
diarrhea, ought to be purged at once, and it is often striking to 
see how the temperature will drop and how much more com- 
fortable the baby will be after a good cleaning out. 

Feeding. — This is the most important part of the treatment, 
and it is in this that mistakes are most frequently made. After 
the initial purge the baby should be deprived of food for about 
twelve hours, being offered nothing but weak barley-water. 
Many babies will take this readily when they will not take 
plain water. The object of the starvation is to empty the 
intestine as completely as possible and to discourage the further 
increase of bacteria by offering them no food on which to grow. 
Starvation must not be used, however, in very weak or toxic 
cases. The principles of feeding are the same in every case of 
sugar fermentation; the details may have to be modified accord- 
ing to circumstances. 

The condition we are dealing with is caused by an excess of 
acid in the intestine from the fermentation of sugar by some 
organism or group of organisms which thrive on sugar. Such 
organisms are likely to be greatly diminished or to die out if 
their principal food supply is withdrawn. Therefore, the great 
principle in treatment is to offer a food which contains very 
little sugar, and a considerable amount of protein, for, as a rule, 
the organisms that thrive on sugar do not thrive on protein. 
Such a food can be prepared in a number of ways, depending 
largely on the resources of the people one is dealing with. 

Protein Milk. — This, or a modification of it, is the ideal 
food, and babies with sugar fermentation do better on it than on 
any other. It is too diflScult of preparation to be used among 
the ignorant, but an intelligent mother can make it satisfac- 
torily. There have been numerous modifications of protein milk, 
but the original preparation is probably as satisfactory as any. 
It is made by rubbing the curds from a quart of milk (prepared 



302 PRACTICAL INFANT FEEDING 

with essence of pepsin) through a fine sieve several times until 
they are in a finely divided condition (see Chapter IX). These 
curds are then mixed with a pint of buttermilk diluted with a 
pint of water. The resulting mixture contains fat 2.5 per cent., 
sugar 1.5 per cent., protein 3.5 per cent. In using all the high 
protein, low sugar milks, dextrimaltose should be added up to 
3 per cent., as if no sugar at all is taken, acidosis may result. 
Such a mixture as this offers but little sugar for the sugar-splitting 
bacteria to grow on, and on account of its high protein content it 
tends to make an alkaline intestine; in an alkaline intestine cal- 
cium soaps tend to be formed, which favor the formation of pasty, 
semisolid stools. The protein milk should be fed in very small 
doses at first — ^perhaps one-fourth as much protein milk as the 
usual amount of milk the baby would take, with the balance 
made up of water. If it is borne well, the amount may be 
rapidly increased. As the baby improves and as the bowel 
discharges become less frequent, small amounts of sugar may 
be gradually added. The best sugar to use is some maltose- 
dextrin preparation, as it ferments less readily than lactose 
does. Protein milk is only a temporary food and should not be 
continued longer than a few weeks. 

In a large city where there is a milk laboratory it is usually 
simpler to have the milk prepared at the laboratory from cream, 
water, and precipitated casein, as any amount of casein or of 
fat desired can be obtained in this way, thus better suiting the 
preparation to the digestion of the individual baby than when 
a stock formula is used. Such a formula prepared at a milk lab- 
oratory would be as follows: Fat 2, sugar 0,^ precipitated casein 
2 .50, lactic acid 0.75 . In all cases it is well to use about 3 per cent, 
of dextrimaltose, as the entire or almost entire withdrawal of 
sugar may be dangerous on account of the possible aggravation 
of an already existing acidosis. Nor is it well to use a very low 
sugar in any case for more than a day or two. 

Skimmed Milk with Powdered Casein. — ^Another satis- 

1 In reality, there is a small amount of sugar present, furnished by the 
cream used in preparing the formula. 



THE DIARRHEAL DISEASES 303 

factory and eminently practical and simple way of feeding is 
with simple dilutions of skimmed or whole milk to which pow- 
dered casein has been added. In the simimer of 1915 I fed a 
good many out-patients by this method, and got very good 
results, fully as good, I beHeve, as could have been obtained with 
the more compHcated ''protein" milk. The chief advantage of 
the powdered casein method is its extreme simplicity, and it is 
probably the best method for general use of obtaining a low 
sugar and a high protein formula. The powdered casein mixes 
very readily with milk and water to form a gruel, and in this 
way it is possible to secure any percentage of casein desired in 
combination with a sufficiently low sugar. The usual dilution 
employed would be: 

Skimmed milk, one-half. 
Water, one-half. 

Powdered casein, up to 2 or 3 per cent. 

This method of feeding is of real importance, and should be 
familiar to every practitioner. There are at present at least 
three powdered casein preparations on the market (see Chap- 
ter IX). 

Lactic Acid Milk. — In some cases lactic acid milk or butter- 
milk feeding may be of value, the idea being that the lactic acid 
organisms of the buttermilk flourish in the intestine and sup- 
plant the organisms that are doing the damage. Buttermilk, 
also, is not very rich in sugar, and contains a good deal of pro- 
tein in an easily assimilable form. It is not possible, however, 
to secure with buttermilk dilutions the high protein percentage 
that can be obtained with the methods already referred to. 
Unless fresh buttermilk can be obtained it is best prepared at 
home from skimmed milk and cultures or tablets containing the 
lactic acid or Bulgarian bacillus. If it is desired to use the lactic 
acid principle, that is, flooding the intestine with lactic acid 
baciUi, it is a great deal better to give the bacilli in the form of 
lactic acid milk than to use simply tablets or vials of the culture, 
as infinitely more bacteria can be given in the first way than 



304 PRACTICAL INFANT FEEDING 

the second. It is worth while, however, if after persistent 
trial, the baby refuses the sour milk,^ to try the liquid cultures, 
one-half a tube three or four times a day. The tablets I have 
no faith in. 

The lactic acid milk plan of feeding is used a good deal, and 
in some cases is very efficient, particularly if the intestinal con- 
tents are infected with the gas bacillus. 

Simple skimmed milk dilutions (boiled) are the best thing 
to use if a high protein milk or lactic acid milk cannot be obtained. 
One would begin with one-third or one-half skimmed milk, the 
rest being barley-water or water, and would increase the con- 
centration of milk gradually as the stools became better. By 
this method improvement is not so rapid as it is with a high 
protein milk or with lactic add milk, but where no facilities for 
anything better are at hand or in dealing with very ignorant 
patients, it works fairly well. 

Medicinal and Other Treatment 

Colonic Irrigations. — If seen at the onset, a high colonic 
irrigation with physiologic sodium chlorid solution may do a 
great deal of good by helping to empty the intestine. Later in 
the course of the disease it does less good, and, indeed, is likely 
to do more harm than good by irritating and disturbing the 
child. 

Water. — Next to the feeding, the free administration of 
fluid is of the utmost importance. The baby is losing a large 
amount of fluid from the body in the water discharges, and it is 
vital to the chemistry of the body, for many reasons, that the 
blood and tissues should not be dehydrated. Howland and 
Marriott believe that a large amount of the acidosis that is seen 
in these cases is caused by retention, owing to anuria, of acid 
sodium phosphate. Marriott has also shown that the blood is 
very much dehydrated in all cases with evidences of intoxica- 

1 Almost all small babies take lactic acid milk readily. Many babies 
over a year old refuse it at first, but if no other food is given, usually will take 
it when they get hungry. 



THE DIARRHEAL DISEASES 



305 



tion, and he believes that most of the toxic symptoms are caused 
by dehydration. He has even substituted the term "anhy- 
dremia" for ''ahmentary intoxication." It may be seen, there- 
fore, that at all costs the tissues must be prevented from be- 
coming dehydrated. There are four ways of giving fluid to 
babies with diarrhea: 

By Mouth. — This is, of course, the simplest way, and direc- 
tions should always be left with the mother or the nurse to get 
in all the water possible between feedings, in frequent tea- 
spoonful doses, and to keep an exact chart of the amount that 




Fig. 5. — Sodium bicarbonate. Subcutaneous slough. (Courtesy of Dr. Hyman 

Green.) 



has been taken. If the baby will take fluid well in this way, and 
is not already ''dried out," it will not be necessary to resort to 
the other methods of giving it. 

Subcutaneous Saline. — The subcutaneous injection of normal 
sahne was formerly the method of choice, but has now been 
largely replaced by the intraperitoneal method. In giving 
saline subcutaneously it is best given in the loose tissues of the 
abdominal wall, and not subpectorally, as the weight of the 
fluid on the chest may use up some of the infant's scanty store 
of strengh. It is given with an ordinary large glass syringe, 



306 PRACTICAL INFANT FEEDING 

about an 18 gage needle, and a three-way stop-cock, or may be 
allowed to run in by gravity. From 60 to 120 c.c. can be given 
on each side of the abdominal wall, depending upon the size of 
the child. It is readily absorbed, unless the child is in an 
extremely weakened condition, and in a very short time after 
injection no traces of the fluid are to be seen in the tissue. 
Sodium bicarbonate should never be given subcutaneously , as it is 
very irritating, and will almost certainly cause a severe slough 
(Fig. 5). 

Intraperitoneal Saline. — In the last three years the intra- 
peritoneal administration of fluid^ has come into vogue. It 
apparently is without danger if properly performed, and has 
several advantages over the subcutaneous method. In the first 
place, it is not nearly so painful, and does not upset or irritate 
the child so much. This is a considerable advantage, as it may 
be repeated every twelve to twenty-four hours, if necessary, 
without undue discomfort. In the second place, more fluid can 
be given in this way than by the subcutaneous route, and, 
according to the size of the baby, 200 to 400 c.c. may be injected. 
Lastly, it is probably absorbed more quickly, especially in very 
weak, moribund babies, who may have little power of subcu- 
taneous absorption. The same apparatus is used as for the 
subcutaneous injection except that the point of the needle should 
be rather blunt. It is inserted in the midline somewhat below 
the umbilicus, care being taken to see that the bladder is empty, 
and that the abdomen is not distended. The fluid is injected 
slowly, or allowed to run in slowly if given by the gravity 
method, which is perhaps the best for this procedure, as if it is 
put in too quickly there may be some danger of collapse. Fluid 
is given until the abdomen is slightly distended. There is ap- 
parently no danger of puncturing the intestine. 

' Physiologic saline solution is used at a temperature of about 100° F. 
A teaspoonful of salt to a pint of water makes approximately a normal solu- 
tion, of about 0.80 per cent, strength. It should, of course, be sterilized by 
boiling before administration, and every aseptic precaution strictly observed 
as regards the apparatus, skin of the patient, and hands of the operator. 



TBE DIARRHEAL DISEASES 307 

Intravenous injections are especially useful when it is desired 
to give glucose or soda bicarbonate for acidosis, or when imme- 
diate availability of the fluid is essential. A 3 per cent, solution 
of sodium bicarbonate or a 5 per cent, solution of glucose is used, 
and an amount injected equal to about one-sixtieth of the body 
weight (Dunn). It is best given into the veins of the scalp, or 
the jugular, if these are available. If not, it may be given into 
the superior longitudinal sinus, a procedure which is com- 
paratively safe, and very easy to carry out, but which, in my 
opinion, should not be used if , the other veins are available. A 
short, blunt needle, attached to a large syringe, is inserted at 
an angle of about 45 degrees in the midline, at the posterior 
angle of the fontanel. The piston of the syringe is slowly with- 
drawn a little, and if the needle has entered the sinus, blood 
will appear on the syringe. The injection should be made 
very slowly, and if the pulse or respiration become poor, or 
if distention of the veins of the scalp appear, should be 
stopped. 

Drugs. — Precipitated Chalk. — This is, I believe, of consider- 
able value, as it helps in neutralizing the irritating acids that 
have been formed in the intestine; i teaspoonful can be given 
mixed with each feeding. The soluble alkalies are useless to 
give for this purpose, as they are largely absorbed in the stomach 
and never reach the intestine. 

Opium. — It is often difficult to know whether or not to give 
opium. It is contraindicated if the bowel movements are few 
in number, if there is a high fever, or if there is much evidence 
of toxemia. It is always contraindicated at the onset of an 
attack, as it is essential to empty the intestine and not to tie 
it up. In other cases it is distinctly indicated, and it is not good 
therapeutics to slavishly follow a set rule and to refuse to give 
opium in any case of diarrhea, as an experienced practitioner 
did with whom I once saw a case in consultation. The child 
had been sick over a week, and was having from twenty to 
twenty-five movements a day, with a great deal of tenesmus 
and discomfort. She was much exhausted from all this, and 



308 PRACTICAL INFANT FEEDING 

still the doctor refused to give the small doses of paregoric which 
I suggested because he "knew it was always wrong to give 
opium in any diarrhea.'^ In such a case as this opium in some 
form, preferably paregoric, is distinctly indicated, for although 
diarrhea is undoubtedly a conservative process, it may exhaust 
the child so much that it does him more harm than good. 

Bismuth. — This drug is sometimes highly recommended, and, 
again, many authors say it is useless. It probably does more 
good in the true infectious type of diarrhea, where there is actual 
ulceration of the intestine, than in the fermentative type which 
we are discussing; in those diarrheas due to sugar fermentation 
I should much prefer precipitated chalk. 

Stimulants are often needed, and there is probably none 
better than brandy or caffein. Epinephrin has been highly 
recommended by some, but its action is so transitory that its 
value seems somewhat doubtful, except to tide over a sudden 
collapse. 

The electric fan is better than most drugs in the treatment 
of any severe diarrheal disease in a baby in very hot weather. 
The baby should be, of course, dressed very lightly in a band, 
diapers, and cotton night dress. The fan should not blow di- 
rectly on the baby, but should be put on a chair or table, and 
directed so that the air from it will blow about 2 feet over him. 
There is no danger of "catching cold" if this rule is observed, 
and a fan is a great comfort to any baby, especially at night, in 
very hot weather, whether he is sick or well. 

Excoriated Buttocks. — If the buttocks are badly excoriated 
it is best not to use a diaper, but merely to put a pad of absorbent 
cotton under the baby, and change it after each defecation. 
Each time the pad is changed the buttocks should be gently 
washed with water and dried. In my experience the two best 
applications have been the following: 

1. Two ounces of lime-water and 2 of olive oil are put into a 
bottle, are shaken vigorously immediately before each appli- 
cation, and the resulting emulsion smeared frequently over the 
buttocks. 



THE DIAR]RHEAL DISEASES 309 

2. B. Bismuth subcarbonate 3ij: 

Lime-water q. s. 

Anhydrous lanolin ad. §ij. — M. 

S. — Apply locally. 

This makes a very thick, sticky paste, and acts as a very effi- 
cient protection to the excoriated skin. 

Protein Form of Fermentative Diarrhea 
The protein form of fermentative diarrhea is not nearly so 
common as the carbohydrate form. In this condition the intes- 
tinal contents have been infected with bacteria which feed 
mostly upon protein, and the resulting stools are brown, foul, 
and alkaline instead of being green, sour smelling, and acid. 
The general symptoms are similar to those of the carbohydrate 
form, but the differentiation of the two should off'er little diffi- 
culty owing to the difference in the stools. The treatment is 
the same with the exception of the feeding. Here a low protein 
and a fairly high carbohydrate diet is needed. Ordinary milk 
modifications with low protein and high carbohydrate added in 
the form of lactose and starch sometimes work very well. Lactic 
acid milk dilutions with the addition of lactose and starch are 
also valuable. This diarrhea is more likely to be caused by 
organisms introduced from without in bad milk than to any 
faulty digestion on the part of the baby. 

INFECTIOUS DIARRHEA 

In this disease we are dealing with a true infection of the 
intestinal mucosa due to some specific organism, usually the 
dysentery bacillus, but occasionally the gas bacillus or strepto- 
coccus. Combined with infection of the mucosa there may be 
also a certain amount of decomposition of the intestinal contents. 
The condition has been called by many names, but the term 
"infectious diarrhea" is the best one, as it serves to differentiate 
it from the fermentative group of diarrheas. Infectious diarrhea 
may arise in a number of ways, the most common one probably 
being direct infection of the mucosa by dysentery bacilli taken 
in per os. Or the process may in many cases start as a fer- 



3IO PRACTICAL INFANT FEEDING 

mentative diarrhea, and for the first few days there may be no 
invasion of the mucosa. Then, if the organisms gain ascendance 
and are of the right variety, the already irritated mucosa is 
attacked, turning the fermentative diarrhea into one of the true 
infectious type. Occasionally a mechanical diarrhea may change 
into an infectious, owing to the fact that the mechanical irrita- 
tion of the intestine prepares the way and allows bacteria to 
invade the injured mucous membrane. There has been much 
discussion as to the organisms that cause infectious diarrhea, 
but the consensus of opinion is that most cases are due to the 
dysentery bacillus. The streptococcus and the Bacillus aerog- 
enes capsulatus are also probably etiologic agents in some 
cases. Infectious diarrhea is often a true epidemic disease, and 
is spread for the most part in the same way that typhoid fever 
is spread — by "fingers, food, and flies." 

In Boston the epidemic usually starts the middle part of 
July, continues through August, and in especially hot summers 
into the first part of September. In the South it starts earlier, 
the last part of May and the month of June usually being the 
worst months. Isolated cases may, however, be seen at any 
time. Young babies are by no means immune, but more cases 
of infectious diarrhea are seen in babies over nine months old 
than in those under. The reverse is true for fermentative 
diarrhea. Older children are likewise not infrequently attacked. 
In fermentative diarrhea there is usually no demonstrable 
pathologic lesion of the intestine, save perhaps a certain amount 
of reddening of the mucosa; in infections diarrhea there may be 
a severe catarrhal or membranous inflanmiation of the mucosa 
of the lower part of the ileum and of the colon, or innumerable 
small punched-out ulcers may be seen. The mesenteric lymph- 
nodes are usually enlarged and injected, and dysentery bacilli 
have in some cases been recovered from the blood. Secondary 
streptococcic infection is not uncommon, which may cause 
septicemia, bronchopneumonia, or otitis media. 

Symptoms. — The onset of infectious diarrhea is varied. It 
may be very sudden in true dysentery infections where the 



THE DIARRHEAL DISEASES 31I 

offending organism is of a virulent strain, and I have seen a 
case start with a temperature of 105° F., with no diarrheal symp- 
toms until the next day. In most cases the onset is more 
gradual, however, and is first made known by diarrhea and 
moderate fever. There will usually be about eight or ten stools 
a day, but in some cases there may be as many as twenty. The 
stools at first are large, and may contain no blood, resembling 
those of fermentative or mechanical diarrhea. In the course of 
a day or two blood begins to appear, and is practically always 
present during the course of the disease, mixed intimately in 
bright red streaks with the mucus and pus. The stools may be 
very small and often contain no fecal material, but consist 
merely of mucus, pus, and blood. They are not usually offensive 
in character, and are more likely to be alkaline than acid in 
reaction owing to the large amount of mucin they contain, which 
is a protein and decomposes rapidly. There is always a certain 
amount of putrefaction of mucus, pus, blood, and other intestinal 
secretions going on, and there may be added to this in certain 
cases a considerable fermentation of carbohydrate food within 
the bowel, in which case the stools will be strongly acid in reaction 
and will smell sour. 

The condition varies a great deal in its severity, according 
to the virulence of the offending organism. Many patients do 
not have a temperature above 101° F., only slight evidences of 
toxemia, and do not seem very sick, but still have many typical 
stools every day. Others will show extreme toxemia, with 
high temperature from the start, and may die in a few days 
despite all efforts at treatment. Toxemia and not the number or 
character of the stools is the criterion of the severity of the case. 

There are likely to be colicky abdominal pains, and a good 
deal of very uncomfortable rectal tenesmus with each move- 
ment of the bowels, accompanied in not a few cases by prolapse 
of the rectum. Nervous symptoms, such as twitching, con- 
vulsions, delirium, and retraction of the neck, are not uncommon 
in severe cases, and are of bad prognostic significance. The 
body rapidly becomes drained of fluid on account of the diarrhea. 



312 



PRACTICAL INFANT FEEDING 



and acidosis may develop, as shown by hyperpnea, in much the 
same way that it does in diarrhea of the fermentative type. 
Gastric disturbance at the onset is common; during the course 
of the disease it is the exception rather than the rule, but when 
present may be rather hard to control. The most common 
complications are bronchopneumonia, pyelitis, and otitis media. 

Diagnosis. — It is rare to see a case of infectious diarrhea 
without blood and pus in the stools, and for practical purposes 
this is the best way of distinguishing it from fermentative 
diarrhea. In the latter condition blood in the stools may be 
seen, but there is never very much of it, and it never lasts long. 
Large amounts of macroscopic pus are usually seen in infectious 
diarrhea, while in fermentative diarrhea such an occurrence is 
not so common. The temperature curve is also of considerable 
assistance in diagnosis. It may be high or low in either condi- 
tion, but in fermentative diarrhea it rapidly drops as soon as 
the intestine is emptied and proper feeding instituted. In 
infectious diarrhea, on the other hand, the temperature is 
likely to continue for a week or more, in spite of purgation and 
proper feeding. 

On account of the bloody stools in both conditions intus- 
susception is not infrequently confused with infectious diarrhea, 
the usual mistake being to overlook the intussusception and to 
call it infectious diarrhea. 

The following table shows some of the main differences be- 
tween the two conditions: 



Infectious Diarrhea. 
Onset: Usually with a fer- 

' mentative diarrhea, 
or if sudden, with a 
good deal of fever. 
Temperature: Usually elevated. 
Vomiting: Usually not marked. 
Distention: Not distended, more 
likely a sunken ab- 
domen. 
Abdominal None, 
tumor: 



Intussusception. 
Sudden, without fever or diarrhea at 
first. Blood appears soon in the 
stools. Abdominal pain marked. 

May be normal. 
Marked — may be fecal. 
Markedly distended in most cases. 



Sausage-shaped tumor felt in four- 
fifths of cases. 



THE DIARRHEAL DISEASES 313 

Treatment. — The general treatment is much the same as 
that for fermentative diarrhea, which has already been out- 
lined. The principles of feeding, however, are quite different. 
As regards diet, cases of infectious diarrhea must be divided 
into two groups, for the feeding in the two groups is radically 
different. The first group includes cases caused by the dysen- 
tery bacillus, or more rarely by the streptococcus or possibly 
the colon bacillus. The second group is caused by the gas 
bacillus (Bacillus aerogenes capsulatus). 

As far as the symptoms and gross characteristics of the 
stools are concerned, it is impossible to tell into which group a 
given case falls. However, there is a simple stool test (see below) 
which serves to differentiate these groups. While the stool test 
is being made, or if for any reason it is not made, the case should 
be treated as a dysentery case, for this is by far the most common 
type. The therapeutic test is of some value, although rather 
haphazard, and if the child does not do well on the dysentery 
treatment, it should be changed to that for the gas bacillus. It 
is always best at the onset, however, to test the stools for the 
gas bacillus, as the test is simple, and it gives much valuable 
information as to the proper feeding. 

Technic of Gas Bacillus Test. — ^A U-shaped fermentation 
tube and a test-tube are filled with concentrated nitric acid, 
and permitted to stand three minutes, when the nitric acid 
is poured out. Both tubes are rinsed thoroughly with tap- 
water. 

A small bit of stool, about i teaspoonful of dextrimaltose, 
and about 15 c.c. of hot tap- water are placed in the test-tube, 
and the mixture is boiled vigorously for half a minute. The 
contents of the test-tube are now poured into the fermentation 
tube, care being taken that it is filled up to the top, and that no 
air-bubbles remain in it. The tube is plugged with flamed 
cotton and kept in a warm place for twenty-four hours. 

Gas in the top of the tube indicates that the gas bacillus is 
present in greater or lesser numbers, depending on the amount 
of gas formed. If the gas bacillus is present in sufficient nimi- 



314 PRACTICAL INFANT FEEDING 

bers to be the etiologic agent of the diarrhea, the tube will 
probably be "blown out," that is, entirely filled with gas. 

Another simple way of testing for the gas bacillus is to plant 
a portion of stool in half a test-tube of boiled milk and incubate 
twenty-four hours. If the gas bacillus is present the milk will 
be coagulated, will smell like rancid butter, and will be shot full 
of holes like Swiss cheese. 

If the "gas test'' is negative, assume that the case is one of 
dysentery infection, and treat it as such. 

Feeding in Dysentery Cases. — The feeding in these cases is 
based on the fact that when offered protein food the dysentery- 
bacillus grows very readily and produces large amounts of toxin. 
On carbohydrate food it does not produce so much or such deadly 
toxin. This applies likewise to the streptococci and pathogenic 
colon bacilli which are commonly associated with dysentery 
infections. Therefore a baby with dysentery should be fed on a 
low protein and a high carbohydrate food. This is theoretically 
sound, works well in practice, and is probably the most suc- 
cessful feeding known for dysentery patients. A few years ago 
it was the custom to starve patients with infectious diarrhea, 
and we used to feed many on weak barley-water or lactose-water 
exclusively for a week or ten days. Many of these patients 
died, probably as much from starvation as from the disease. 
During starvation the bacteria causing the disease live upon the 
intestinal secretions, which are protein in character, and from 
which they can readily produce toxin. The old treatment with 
albumen-water and meat broths is distinctly contraindicated. 

According to our present ideas a year old baby with dysen- 
tery would be treated about as follows: 

Purgation. — ^A brisk purge at the onset is distinctly indicated 
in order to empty the bowel of as much toxic material as possible. 
Castor oil is the best purge if it can be kept down, and a table- 
spoon would be given to a year old baby. If the stomach is 
irritable, calomel is used, in ten divided doses of tu grain each, 
and followed in about two hours with two teaspoonfuls of milk 
of magnesia. During the course of the disease routine purga- 



THE DIARRHEAL DISEASES 315 

tion should not be used, but should be employed only if the 
number of stools have lessened and the toxemia has increased. 

Starvation. — For twelve hours all food except water is with- 
held. This is in order to thoroughly empty the digestive tract, 
and during this stage the water should be forced, in small fre- 
quent doses. 

Feeding. — ^After the initial starvation period a 7 or 8 per cent, 
lactose solution in barley-water is given, 6 to 8 ounces every 
2 J or three hours. This would ordinarily be kept up twenty- 
four to forty-eight hours. Then the regular feeding is begun, 
the principle being to add small amounts of protein in the form 
of boiled skimmed milk or fat-free lactic acid milk, to the lactose 
and barley-water solution, and to gradually increase it during 
the course of the disease, as the stools become better. Lactic 
acid milk is, I think, usually a good deal more efficient than 
ordinary skimmed milk. One would begin with a formula of 
about the following strength: 

Fat-free lactic acid milk, 2 ounces. 
Barley-water, 6 ounces. 

Lactose, up to 7 or 8 per cent. 

If lactic acid milk is not available, dried milk or boiled 
skimmed milk would be used. Condensed milk would also be 
suitable. As the baby begins to improve, and as the stools 
become less frequent and more normal in character, the strength 
of the formula is increased, until it would consist of undiluted 
or only slightly diluted fat-free lactic acid milk, with lactose 
added up to 7 or 8 per cent. At this stage a few tablespoonfuls 
of barley or rice jelly a day is added, or zwieback soaked in fat- 
free milk. The last thing to do is to increase the fat in the 
mixture, as these babies bear fat very poorly, and many cases of 
chronic indigestion have been caused by adding fat too soon and 
in too large amounts. The loss of weight is, of course, consid- 
erable, and the natural tendency is to push food, but it is far 
better to go slowly and cautiously, and to avoid the danger of 
a relapse. Not a few cases of severe marasmus follow over- 



3l6 PRACTICAL INFANT FEEDING 

feeding during the convalescent period of infectious diarrhea. 
After the stools become normal it is best, if the baby is doing 
well on the lactic acid milk and lactose mixture, to continue it 
for some weeks, with the addition of 1 or 2 per cent, of fat, 
rather than to try to get him back rapidly to ordinary whole 
milk. If during the course of treatment the stools should become 
more frequent, acid, and sour smelling, this is an indication 
that too much sugar is being given, and that it is being fer- 
mented. Under these conditions a reduction or entire omission 
of the lactose for two or three days is indicated. It is quite 
likely that the baby will not digest all the food that is given 
him under this regimen, but he will come through the disease 
in much better condition than if he is starved, as under the 
older method of treatment. The feeding in the "gas bacillus" 
type of case is different, and patients with this form of infectious 
diarrhea always do better on lactic acid milk with a low sugar 
content than with any other form of feeding. The lactic acid 
bacillus seems to be directly antagonistic to the gas bacillus, 
and drives it out of the intestine very quickly. Furthermore, 
the relatively low carbohydrate and high protein content of 
lactic acid milk is indicated, as the gas bacillus is an organism 
which thrives on carbohydrate food, but does poorly on protein. 
Protein milk, which has already been discussed in the section on 
Fermentative Diarrhea, hkewise fulfils the indications for feeding 
in this group of cases. 

The exact relationship of the gas baciUus to infectious diar- 
rhea is under some dispute, and some observers believe that it 
is not at all the etiologic agent of the disease, but merely present 
as a relatively inoffensive saprophyte. We know, at any rate, 
that it is not infrequently present in large numbers, and that 
when we get rid of it by lactic acid milk and low sugar feeding, 
the patient is better. These facts are enough upon which to 
base an intelligent therapeusis, no matter what its exact rela- 
tionship to the disease may be. 

Other Methods of Treatment. — Colonic Irrigations. — A co- 
lonic irrigation at the onset probably does considerable good. 



THE DIARRHEAL DISEASES 317 

During the course of the disease I am very doubtful about its 
value, and it may do more harm than good by irritating and 
disturbing the child. Rest and quiet are two of the most im- 
portant principles in the treatment of any disease. If the child, 
however (especially an older child), is restless and disturbed at 
night on account of tenesmus and frequent bowel movements, a 
colonic irrigation with warm normal saline at about 7 or 8 p. M. 
may get rid of enough mucus and may be soothing enough to 
the lower part of the bowel to prevent such frequent movements, 
and to give him some sleep for the first half of the night at any 
rate. Also, in subacute cases, where pus, mucus, and a Httle 
blood continue in the stools longer than they should, irrigations 
once a day with a pint of 2 per cent, silver nitrate solution may 
be of considerable value. 

Drugs. — Bismuth seems to do good in some cases, probably 
by coating over the Httle ulcers in the intestine. The subcar- 
bonate is the best form to use, and should be given in rela- 
tively large doses (grs. xx or xxx every three hours) with the 
feeding. 

Tannalhin is an organic preparation of tannic acid, and is 
astringent in its action. It is brown in color, inoffensive in 
taste, and may be given either in the form of pills or of powders. 
The dose is about 10 grains every three hours or 15 grains for 
older children. In a few cases I have seen it apparently help a 
good deal by lessening the amount of blood in the stools. It is 
worth a trial. 

Opium. — The same holds true of opium for infectious diar- 
rhea as for fermentative. It is often recommended to give opium 
enemas or suppositories. What the rationale of this is I am sure 
I do not know, as opium is not a local anesthetic, and it works 
no better on the rectum or intestine when given in this way 
than when given by mouth. Furthermore, it will probably not 
be retained. It is always best given by mouth in the form of 
paregoric, or subcutaneously in the form of morphin, if the 
stomach is irritable. 

Fluid. — The same as for fermentative diarrhea. 



3l8 PRACTICAL INFANT FEEDING 

Treatment of Special Symptoms. — Vomiting may be in a few 
cases a very troublesome S3miptom. It is best treated by tem- 
porary withdrawal of food, beginning again with very small, 
frequent doses. An old country doctor in the South told me 
once that small doses of calomel were effective, which from 
later experience I have found to be true in some cases. If these 
two measures are unavailing, stomach washing with a 1 per 
cent, soda bicarbonate solution (about 1 rounded teaspoonful to 
the pint) should be tried. 

Hyperpyrexia. — If the temperature is continuously high 
(105° F.) measures should be taken to reduce it. The best 
method is the cool pack. The baby is wrapped in a large bath 
towel or old blanket wrung out in water at about 80° F. Water 
of this temperature or a little lower is sprinkled over the wrapped- 
up baby, and evaporation caused by fanning with a hand fan 
or still better by an electric fan. This is often very efficient 
both in controlling hyperpyrexia and nervous symptoms. Ice- 
bags to the head are not usually very practical for small 
babies. 

Nervous Symptoms. — Cases with high fever and marked 
toxemia often show severe nervous symptoms. Sodium bromid 
by mouth or cool packs are the best measures of treatment. If 
these do not work, codein may be given subcutaneously. This 
is much to be preferred to morphin in any form, as it does not tie 
up the intestine nearly so much as does the latter drug. Chloral 
is usually not practical, as its taste is very disagreeable when 
given by mouth, and it may upset the stomach. Rectal ad- 
ministration is, of course, not suitable in the presence of a 
diarrhea. 

Collapse. — For sudden collapse subcutaneous injections of 
adrenahn are as good as anything for quick action, but the 
effect is transitory. Brandy, whisky, caffein, camphor, and 
strychnin are also all commonly used. Small doses of brandy 
or whisky are as good as anything. 

Prognosis. — ^Infectious diarrhea should always be con- 
sidered a serious disease, although it does seem, in this locality, 



THE DIARRHEAL DISEASES 319 

at any rate, that it has been milder in the last few years than 
formerly. The prognosis depends mostly on the age and general 
condition of the child and on the virulence of the infection. 
Babies who have previously suffered from chronic digestive 
disturbances are always poor risks, and if they do not die from 
the acute attack, they are not unlikely to develop marasmus 
and die later. The younger the child, the worse the prognosis. 
The virulence of the infection is, of course, of prime importance, 
and this varies greatly in different instances. I have seen 
children go through an attack of infectious diarrhea with only 
mild discomfort and very little fever; others may be doomed 
from the start, and may die in a very few days. The mortality 
is always high, especially the hospital mortality, among the 
poorer classes; but so much depends upon the factors given 
above that it is impossible to give exact figures that mean any- 
thing. 

PROPHYLAXIS OF DIARRHEAL DISEASES 

No raw fruit or vegetables should be given to children 
under five years of age, and care should be taken that all food 
ingested be in a finely di\dded form. Overfeeding should be 
carefully avoided in hot weather, especially overfeeding with 
sugar. It is always good practice during a hot spell to dilute 
the baby's milk one-third with water. Overclothing the baby 
is also to be avoided, and frequent bathing, avoidance of the 
sun, and pro\dding him wath water to drink betw^een his feed- 
ings are all important. In the southern part of this country, 
during the summer, all milk fed to babies, no matter how clean 
it is, should be boiled. An ounce of orange juice daily will 
prevent scurvy. 

In cooler parts of the country, during the hot weather, all 
milk should be boiled with the exception of certified milk, which 
can be given raw; but during very hot, sultry spells this should 
be boiled also. 

There is really no valid argument against using boiled milk 
in the summer time. The only possible harm it can do is to 
produce scurvy. But we know that comparatively few babies 



320 PRACTICAL INFANT FEEDING 

who are fed on fresh boiled milk develop scurvy, and orange 
juice is practically certain as a prophylactic. Undoubtedly 
nature intended babies to have raw milk, but the dangers of 
unclean raw milk so greatly outweigh those of boiled milk, 
especially in the summer, that more and more physicians are 
ordering boiled milk as a routine, and it is the duty of us all to 
educate the laity as to the dangers of raw milk in hot weather. 



CHAPTER XIII 

CHRONIC INTESTINAL INDIGESTION IN OLDER 
CHILDREN 

{Synonyms: Celiac Disease, Intestinal Infantilism) 

Definition. — A chronic condition seen in children usually 
from the end of the first to the third or fourth year, characterized 
by putrefaction or fermentation of the intestinal contents, 
resulting in foul, undigested stools, and followed in severe 
cases by extreme impairment of nutrition. 

Etiology. — It is all too commonly believed that as soon as 
a baby has reached the end of his first year, and is on a mixed 
diet, his liability to digestive troubles is over, and he can eat 
indiscriminately. It is this belief, this overfeeding, either 
qualitatively or quantitatively, that is often responsible for 
chronic intestinal indigestion, a condition very common in its 
milder, and not at all uncommon in its severe, forms. The 
present extreme of overfeeding young babies with a mixed diet 
is not sound, and causes much trouble. While it is probably 
true that a baby needs some food in addition to milk after he 
has reached the eighth or ninth month, it is too often forgotten 
that his digestive tract is not ready for large amounts of solid 
food. Chronic intestinal indigestion usually has its origin dur- 
ing the second year, when the baby is beginning to take many 
new articles of diet, and there can be no question that a 
very large proportion of cases are due to the too early use of 
too much and too varied solid food. The baby's digestive 
tract develops slowly, he has few teeth, and the few that he has 
he does not know how to use, so that the proper preparation 
of the food by the mouth, which is so important with any other 
diet than a liquid one, often means little, even if the baby has 

21 321 



322 PRACTICAL INFANT FEEDING 

a full set of teeth. Overfeeding with starch and vegetables, 
especially potato, is a particularly common cause. Other cases 
begin with an acute fermentative or infectious diarrhea, the 
tolerance for food is lowered, too much food is fed, and chronic 
intestinal indigestion results. The condition may also occur 
in babies who have had considerable trouble with feeding during 
the first year of life, particularly those who have had an in- 
capacity for fat. We know comparatively little of the exact 
processes which go on in chronic intestinal indigestion, but the 
following conception is one which serves as a good working 
hypothesis: There is probably a chronic infection of the con- 
tents of the intestine with bacteria which should not be there; 
this produces a continual fermentation or putrefaction of the 
food before it has had a chance to be digested, the irritating 
products of which may cause a chronic inflammatory condition 
of the mucous membrane of the bowel. The poor absorption 
of food (salts as well as organic material) which naturally follows, 
plus the absorption of certainly a portion of the toxic substances 
which have been formed in the bowel, results in severe mal- 
nutrition and arrested development. The reason why there is 
a bacterial overgrowth in the intestine is that so much undi- 
gested food residue is present that bacteria flourish at all levels 
of the intestine, and when once they have gained a foothold, 
are hard to get rid of. There is probably little deficiency of the 
digestive juices in most cases. The small intestine should be 
relatively free from bacteria, and in it are carried on some of the 
most complicated and delicate chemical reactions that occur in 
the human body. When this locus is infected with bacteria, 
and the food is being attacked by them before it can be broken 
down in the normal way by the digestive juices and absorbed, 
it is easy to see what chaos may result, and how the orderly 
processes of digestion and assimilation may be interfered with. 

According to Herter^ the Bacillus bifidus is very frequently 
found in abnormally large numbers, and he asserts that a very 
striking fact about many cases is that the bacterial flora of the 
1 Intestinal Infantilism, New York, 1908. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 323 

intestine reverts to the early infantile form seen in the breast-fed 
baby. An overgrowth of the ''gas bacillus" (Bacillus aerogenes 
capsulatus) in the intestine is not infrequently found, and 
marked improvement is seen when it has been reduced in num- 
bers by a suitable lactic acid milk diet. According to Sylvester^ 
the gas bacillus is frequently found in stools of normal children 
over three years of age, but when it occurs in younger children 
it is almost always responsible for S3miptoms of indigestion. 

The essential changes in the metabolism consist in a dimin- 
ished absorption of all the food elements, especially fat. The 
absorption of this element is practically always poor, and may 
vary from 60 to 85 per cent. There is also a very poor reten- 
tion of calcium and of magnesium, and there may be an actually 
negative balance (Herter) . 

Symptoms. — The most striking part of the general sympto- 
matology is the interference with the general nutrition, which 
may be extreme, and is analogous to ''marasmus" in younger 
babies. Not only is the child extremely thin, but he is much 
underdeveloped in every way, so much so that Herter has given 
the name of "intestinal infantilism" to the condition. A child 
of three years may weigh only 17 or 18 pounds and be so weak 
that he cannot walk. The face is drawn and sharp, the hair 
usually scanty, and the teeth often poor. Some cases will, 
however, have perfect teeth, which is rather striking, consid- 
ering the general poor nutrition and development. The reason 
for this is that most of the temporary teeth have been calcified 
before the nutritional disturbance has made its appearance. 
The bones are very small and frail; this is particularly notice- 
able, of course, in the arms and legs, which may be mere pipe- 
stems. The most striking thing in the appearance is the very 
large size of the abdomen in relation to the size of the chest. 
It may in some cases be enormous (see plate), and it is not at 
all uncommon to mistake the condition for tubercular peritonitis 
on this account. The large size of the abdomen is due to gaseous 
dilatation of the atonic intestines which easily push the thin and 

^ Boston Med. and Surg. Jour., vol. clxxxiii, No. 9, 1920. 



324 



PRACTICAL INFANT FEEDING 



flabby abdominal muscles outward. It is not at all uncommon 
to find shifting dulness, which is partly due to liquid feces 
shifting about in the bowel, and also sometimes to free fluid in 
the abdominal cavity. The Hver may be considerably enlarged, 
the spleen occasionally. There is the general enlargement of 





Figs. 6 and 7. — Chronic intestinal indigestion. 

superficial lymph-nodes which so often goes with malnutrition 
in infancy and childhood. A secondary anemia is common, and 
a good many of these children have an associated rickets or 
may show no signs of it. They are often extremely nervous and 
irritable, and have a peculiar, fretful cry. There is often a 
fever of slight degree. Despite the fact that the rest of the body 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 325 

has developed so poorly, the development of the brain is usually 
little interfered with, and the mind is likely to be quick and 
active, although the disposition is peevish. The stools are 
always very foul, and in a hospital ward it is usually possible to 
pick out a case of chronic intestinal indigestion by the aroma 
which hangs about the bed. The stools may be formed and 
constipated, of a light color and rather clayey consistency, or 
there may be periods in which they are loose and mushy, with 
large amounts of mucus. They may contain a large excess of 
fat or of starch, depending upon the type of case, and may be 
acid or alkaline, according to the kind of food that is being 
decomposed. The appetite is usually good, and in most cases 
there is no vomiting. The urine very frequently contains an 
excess of indican. 

Diagnosis. — In the ordinary case the diagnosis is not at all 
difficult. The history, the appearance of the child, and the 
character of the stools are all of importance. It is, of course, 
necessary to rule out any other wasting disease. Tuberculosis 
is the most important in this connection, and many cases are 
sent to the Children's Hospital each year with the diagnosis of 
tubercular peritonitis. In some instances the differential diag- 
nosis between chronic intestinal indigestion and tubercular 
peritonitis may be extremely difficult, and I can well remember 
several cases in which the wrong diagnosis was made after we had 
had the opportunity of stud3dng the child in the wards for a 
considerable period. In the typical case of tubercular perito- 
nitis of the ascitic type, with a large amount of fluid in the 
abdomen, there is no difficulty; it is the borderline cases, with a 
small amount of fluid, which are difficult. The table on page 
326 will perhaps show as well as anything the points of 
difference. 

Treatment is difficult, but with persistence good results may 
be obtained. It is almost entirely dietetic, and the principle is 
to adapt the diet to the child in such a way that the particular type 
of bacterium with which the intestinal contents is infected will 
have no unabsorbed food upon which to grow. This depends upon 



326 



PRACTICAL INFANT FEEDING 



Chronic Intestinal Indigestion. 



Temperature: 


Usually not much 




elevated. 


von Pirquet: 


Negative under two 




years. Positive or 




negative after this. 


Stools: 


Much evidence of in- 




digestion. 


History: 


Suggestive. 


a:- Ray: 


No tuberculosis else- 




where. 


Abdominal 


Thin and very flac- 


wall: 


cid. 


Mesenteric 


Usually no striking 


lymph-nodes: 


enlargement. 



Tubercular Peritonitis. 
Considerable irregular fever. 

Usually positive. 

Not so much evidence of indigestion. 

History of exposure important. 
May show tubercular tracheobron- 
chial lymph-nodes or lung. 
Thick and doughy. 

Often many easily palpable glands. 



the fundamental truth first recognized by Escherich, that it is 
possible by a regulation of the type of food to regulate the type 
of intestinal flora. The first step is to determine whether the 
intolerance is chiefly for fat or for starch, or for both. Some 
cases will have an intolerance for sugar, but fat and starch are 
by far the most common causes of the trouble. The deter- 
mination of what element or elements are not being digested is 
of vital importance, and must be accomplished before intelligent 
treatment can be begun. Stool examination is here essential. 
Many times the distinction is quite clear, and the child may be 
able to handle a considerable amount of fat and no starch, or 
vice versa, but often and, indeed, in most cases the digestive 
power for both fat and starch is considerably lowered. The 
stools of a starch case are usually large and loose, of mushy 
consistency, with many little gelatinous masses of undigested 
starch and cellulose, of a fermented '^pig-pen" odor, and show 
under the microscope when stained with Lugol's solution innu- 
merable small masses of black undigested starch. In the pure 
fat cases they are likely to be more smooth and sticky, of a 
light color, and a foul smell, and under the microscope, when 
treated with acetic acid and soudan III, many fat globules are 
seen. If sugar is at fault and the other elements are not, there 
may or may not be an excess of fat or of starch under the micro- 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 327 

scope, but the stool will be loose and spongy, with an excessively 
acid reaction and a sour smell. Protein very rarely causes 
trouble, and in most cases of chronic intestinal indigestion is 
tolerated in large amounts. 

We have, then, broadly speaking, four types to consider 
as regards treatment: 

1. Essentially fat. 

2. Essentially starch. 

3. Essentially sugar (relatively uncommon in older children). 

4. Mixed starch and fat (most common type). 

The principle of treatment is to regulate the diet in such a 
way that the offending element will be reduced to a minimum, 
so that whatever organism or organisms are flourishing upon 
it will be starved out, having no suitable pabulum upon which 
to grow. The calories withdrawn by the withdrawal of this 
element are replaced by other substances which are non-ferment- 
able by the particular intestinal flora one is dealing with. 

In planning the diets it is necessary to write down every- 
thing in exact amounts; it is never sufficient to give verbal 
directions or to leave any leeway in amounts. I use for this 
purpose cards, about 8x5 inches, which are very convenient, 
and which can be tacked up in the kitchen or pantry, so that 
no mistakes will be made (see Chapter VIII) . 

The food must be regarded as medicine and must be given 
as such. Nothing whatever can be given except what is on the 
diet list. The diet must be arranged as carefully and adhered 
to as closely as that of a severe diabetic would be. It is always 
well to calculate the calories, and it is often helpful to know the 
number of grams of each food element that the child is taking. 
Calories in connection with chronic intestinal indigestion are 
often misleading, as these children always need a good many 
more calories per kilogram of body weight than a normal child 
of the same age does, and it would therefore be useless to attempt 
to follow any set rule for the number of calories needed by chil- 
dren of different ages, or to foUow the normal standard, except 
in a very general way. 



328 PRACTICAL INFANT FEEDING 

Table of Food Values (From the Children's Hospital, Boston. Pre- 
pared BY Dr. J. L. Morse) 

Grams: 

Calories. F. C. P. 

Whole milk, 1 quart 670 38 43 34 

Skimmed milk, 1 quart 400 10 43 35 

Gravity cream, 1 pint 860 77 22 14 

Buttermilk, 1 quart 360 5 43 35 

Whey, 1 quart 260 5 43 9 

Beef juice, 1 ounce 10 ^ 2 

Crackers, 1 ounce^ 120 3 20 3 

Bread, 1 slice"' 75 « ^5 3 

Zwieback, 1 slice^ 120 3 20 3 

Shredded wheat biscuit 105 ^ 22 3 

Rolled oats (cooked), 1 tablespoonfuH 35 ^ 55 ^ 5 

Cream of wheat, Ralston, and similar cereals 

(cooked), 1 tablespoonful* 40 8.5 1.5 

Potato, size of large egg^ 70 15 2 

Macaroni (cooked), 1 tablespoonful 30 « 5 1 

f Whole 72 5 7 

Egg i Yolk 60 5 4 

[ White 12 3 

Meat (cooked), 1 ounce'' 

Fish 60 3 7 

Bacon, 1 slice = ^ ounce 90 9 1.5 

Butter, U-inch cube = 1 ounce 225 24 

Olive oil, 1 tablespoonful 125 14 

American cheese, Ij-inch cube = 1 ounce 130 10.5 8.5 

Cream cheese, l|-inch cube = 1 ounce 130 10. 5 8.5 

cane-, 1 rounded teaspoonful 25 6 



' milk-, 1 rounded tablespoonful 60 15 

J . , / (cooked), 1 tablespoonful* 40 

Lima beans J 

Carrots 

Squash 

Turnip \ (cooked), 1 tablespoonful* 30 

Beets 

Onions 

Orange, medium sized 50 13 

Apple, medium sized 70 17 

Banana 115 1 24 2 

Prunes, 4 without sugar 30 7 

^ Crackers vary so much in size that they must be weighed to determine 
how many it takes to weigh an ounce. 

2 Bread, 1 slice 4 inches square and f inch thick = 1 ounce. 

3 Zwieback, 1 slice ^ large slice. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 329 

The following table by Holt and Fales^ shows the caloric 
requirements of normal children of different ages: 





Total C 


\\L OKIES 




Age, years. 


Average weight, 
pounds. 


Boys. 


Girls. 


1 


22 


950 


940 


2 


27 


1135 


1110 


3 


32 


1275 


1230 


4 


36 


1380 


1300 


5 


40 


1490 


1410 


6 


44 


1600 


1520 



Articles of Food Used. — Milk soured by the lactic acid 
bacillus is almost always to be used in preference to sweet milk. 
Ordinary buttermilk may be employed, or, still better, it may 
be made from one of the cultures of lactic acid bacilli which 
are on the market. By flooding the intestine with lactic acid 
bacilli the growth of saprophytic organisms is inhibited, and 
children with chronic intestinal indigestion almost always do 
better on lactic acid milk than they do on ordinary milk. Where- 
as with the normal child of from one to three or four years of 
age it is not ordinarily desirable to give more than 24 to 32 
ounces of milk a day, in children with chronic intestinal indiges- 
tion it is often advisable to give considerably more than this 
of the lactic acid milk, and many children may take as much 
as 50 ounces a day with benefit. In the beginning they usually 
do not like it, but it is rare to find any child who will not take 

lAmer. Jour. Dis. Chll., vol. 21, January, 1921. 

^ A tablespoonful means as in ordinary serving, not level. 

^ The lean of a lamb chop weighs about an ounce ; so does a piece of 
meat about l|-inch cube or a thin slice of beef. 

^ These foods contain from i to | gram of fat in each of the quantities 
given. 

Clear soups and broths made without rice or barley have practically no 
nutritive value. 

The nutritive value of the "fodder" vegetables, such as spinach, string 
beans, asparagus, lettuce, celery, cauliflower, cabbage, eggplant, tomatoes, 
and cucumbers, is so slight that they may be disregarded. 

iPears and peaches have about the same value as apples of the same size. 



330 PRACTICAL INFANT FEEDING 

it after a few days, although it may be necessary to withdraw- 
all other food for a day or two until the child gets so hungry 
that he is glad to take anything. Not more than 2 per cent, 
of fat should ever be used in lactic acid milk, as preparations 
containing more than this are too thick. A few ounces of sweet 
milk may be allowed each day for use on the cereal taken, if 
cereal is allowed, but the cornerstone of the diet should be lactic 
acid milk. In cases with an intolerance for sugar it may be neces- 
sary to use a milk with even less sugar in it than there is in lactic 
acid milk. For these cases Finkelstein's protein milk or some 
modification of it is indicated. If lactic acid milk or protein 
milk is not well borne, boiled fat-free milk is used. 

Starch. — The hardest form of starch to digest is potato 
starch, and potato in any form should never be given to these 
children, whether the case be one of fat or of starch indigestion, 
or a combination of the two. Rice jelly, barley jelly, farina, 
dry toast, or zwieback are the best forms of starch to use. Zwie- 
back and rice jelly are probably the most digestible. 

Fat. — In the fat cases a fat-free milk must be used over a 
long period of time, and sometimes even the fat contained in 
the yolk of an egg will cause an upset. In the starch or in the 
mixed cases a 2 per cent, fat will usually be tolerated. Some- 
times olive oi] is well borne when butter fat is not, and a table- 
spoonful of this two or three times a day is often of consider- 
able value. A tablespoonful of olive oil weighs 14 grams, and 
furnishes 125 calories. In some cases homogenization of the 
olive oil with lactic acid milk works remarkably well, and is 
worth a trial if fat cannot be tolerated in any other form, and 
if the tolerance for the other food elements is low. 

It may be necessary in severe cases to keep the child on a 
practically fat-free diet for several months, and when fat is 
begun it should be added very slowly and in small amounts. 

Protein. — For some reason protein is the best borne of all 
the food elements in cases of chronic intestinal indigestion, 
and a diet very high in protein is almost always advisable. The 
protein under such conditions is used not only as a tissue 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 33 1 

builder but also takes the place of fat or carbohydrate for fuel 
purposes. Meat is of the utmost value, and is usually well 
tolerated even in large amounts. While it is ordinarily not 
desirable to give meat to normal children until they are about 
two years old, it may be given in considerable amount to chil- 
dren of sixteen or seventeen months old with chronic intestinal 
indigestion. To older children it may sometimes be given with 
every meal, especially if the starch tolerance is low, and little 
or no starch is being taken. It should always be finely scraped, 
and the child should be taught to chew thoroughly. The white 
meat of chicken contains less fat than either lamb or beef, and 
is, therefore, the best meat to use in fat cases. 

Eggs in many cases are well borne, in others not. The 
yolk of an egg contains about 5 grams of fat, and this should be 
remembered in cases with a severe fat intolerance. Sometimes 
the white seems to be more indigestible than the yolk, and if 
this is so, the yolk can be advantageously given alone by hard 
boiling the ^gg, separating yolk from white, and grating it into 
the cereal or meat. 

Cottage cheese is often of considerable value, and makes an 
excellent substitute for butter. It contains about 30 per cent, 
of protein and 1 per cent, of fat; full cream cheese contains 26 
per cent, of protein and 34 per cent, of fat. 

Cottage cheese can be easily made at home from skimmed 
milk. Add two teaspoonfuls of essence of pepsin to 24 ounces 
of skimmed milk, and let it stand in a warm place for half an 
hour. Break up the curd with a knife and strain off the whey. 
Squeeze the curd in a cheese-cloth bag until practically all the 
whey has been removed. Salt to taste. The resulting product 
should be slightly moist and granular. It consists of calcium 
and of casein, and may often be used with a great deal of 
advantage. A tablespoonful three times a day is not too much 
to begin with. 

Sugar. — In some cases the sugar tolerance is poor, and 
fermentation results if any sugar is given. In other cases large 
amounts of sugar may be given without disturbance, and the 



332 PRACTICAL INFANT FEEDING 

caloric value of the diet may be very materially raised in this 
way. Indeed, sugar in some form is one of the most valuable 
foods at our command in those cases which have a good sugar 
tolerance, as it is a very concentrated food of high caloric value, 
and enables us to give a high caloric diet in an easily absorbable 
form. Dextrimaltose or corn syrup are the best sugar prepara- 
tions to use. A level tablespoonful of dextrimaltose may be 
added to each 8 or 10 ounces of milk, and furnishes about 36 
calories. Commercial corn syrup contains dextrins, maltose, 
and glucose. On account of the different degrees of rapidity 
with which these carbohydrates are absorbed there is com- 
paratively little chance for fermentation, and therefore this 
preparation often makes a very valuable addition to the diet, 
and may be used in suitable cases in large amounts. It was 
first advocated by Marriott^ in 1919 in the treatment of athreptic 
infants, and applies equally well to older children. If 45 c.c. of 
the corn syrup is mixed with 55 c.c. of water, the resulting 
mixture contains approximately 50 grams of carbohydrate 
(Marriott); 20 c.c. of the mixture, containing 10 gm. of carbo- 
hydrate, adds a little over 3 per cent, carbohydrate when mixed 
with a 10-ounce feeding of milk. I happen to be treating now 
a most difficult case of chronic starch indigestion in a girl three 
years old, and nearly one-half of her 1400 calories is furnished 
by the 150 gm. of carbohydrate which she takes each day in 
the form of corn syrup. The use of large amounts of corn syrup 
applies especially to severe starch cases, in which it is extremely 
difficult to keep up the caloric value of the diet after all or nearly 
all of the starch has been omitted. 

Vegetables. — Our aim in treating chronic intestinal indiges- 
tion is to furnish a diet of easily digestible, concentrated food 
with as high a caloric value as possible. Green vegetables are 
of such slight caloric value that they are not of much use in the 
diets of these cases as far as their caloric content is concerned, 
and, indeed, many children with starch indigestion will become 
upset on account of the cellulose that vegetables contain. It 

1 Jour, Amer. Med. Assoc, vol. 73, No. 16, 1919. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 333 

is well to give a small amount of a vegetable puree every day, 
however, in many cases. Spinach and carrots are the best 
vegetables to use, as they contain a relatively large iron content. 
It must be remembered, however, that it is often necessary to 
feed these children on very pecuhar diets, which may differ con- 
siderably from our ideas of a well-balanced diet for a normal 
child, and in all severe cases vegetables must be withheld, not- 
withstanding their theoretic value as iron and vitamin containers. 

Fruit. — A normal child of two or three years would take 
orange juice in the morning and probably apple-sauce or prune- 
sauce with his evening meal. Fruit should, however, usually 
not be given in any form to cases of chronic intestinal indiges- 
tion, as it has a very small caloric value, and is too irritating to 
the intestine, which we wish to protect in every way possible. 
There is practically no danger of scurvy. 

The following diets show in a general way what might be 
given to children with various types of indigestion: 

Diet I 

For a Baby 2\ Years Old, Weighing 18 Pounds, with Severe Fat Indigestion 
Breakfast 

7 A. M.: 10 ounces fat-free lactic acid milk. 

Dextrimaltose, 1 level tablespoonful. 
Dry bread, 1 slice. 
Lunch 

11 A. M.: 10 ounces fat-free lactic acid milk, 

Dextrimaltose, 1 level tablespoonful. 
Dinner 

2 p. M. : Meat, 2 rounded tablespoons. 

Thick spinach puree, 1 rounded tablespoonful (?). 
Custard, 1 small cupful. 
Fat-free lactic acid milk, 5 ounces. 
Dextrimaltose, 1 level teaspoonful. 
Supper 

6 P. M. : 3 small zwieback. 

Fat-free sweet milk, 3 ounces. 
Fat-free lactic acid milk, 8 ounces. 
Dextrimaltose, 1 level tablespoonfu). 

9 or 10 p. M.: Fat-free lactic acid milk, 10 ounces. 
Dextrimaltose, 1 level tablespoonful. 
Total calories, about 1050. About 57 calories per pound. 



334 PRACTICAL INFANT FEEDING 

Starch. — In many cases of starch indigestion a certain 
amount of starch may be allowed, under which conditions the 
diet is not hard to plan. In the most severe cases it is neces- 
sary, however, to omit all starch, which makes the planning of 
the diet rather difhcult. I will always remember one extremely 
severe case of combined starch and fat indigestion, a girl four 
years old, who had been treated over a period of two years by 
three or four of us without much success. She would do well 
for a while, then would have a severe relapse, and lose all the 
weight she had gained. She weighed at four years less than 25 
pounds, and was in miserable condition. All of us who had 
treated her previously had kept the fat and starch in her diet 
low, but had never omitted starch entirely. The next man who 
tried her omitted aU starch, and fed her nothing whatever but 
lactic acid milk, skimmed milk, corn syrup, and meat, allowing 
very large amounts of lactic acid milk and meat especially. Her 
diet consisted, therefore, entirely of protein and sugars. The 
result was little short of miraculous. She gained several pounds 
in a few months, her progress was steady, and in about six 
months she was a strong, healthy child. The explanation of 
the good results in this case is probably that her intestine was 
infected with some organism or organisms which flourished upon 
starch, and as long as there was even a small amount of starch 
present it was enough to keep the organism alive, and thus to 
allow a certain amount of fermentation to be continually present. 
The entire withdrawal of starch from the diet over a consider- 
able period of time caused the organism to slowly die out, as it 
had no food to grow upon. This principle of feeding no starch 
whatever is of the utmost importance^ and should be used in all 
severe starch cases. ^ 

^ If it is necessary to omit all starch, biscuits or bread made from one of 
the casein flour preparations which are so commonly used by diabetics make 
often a most welcome and valuable addition to the diet. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 335 



Diet II 

For a Moderately Severe Starch Case. Age 2\ Years. Weight 20 Pounds 

Breakfast 

7 A. M.: 2 per cent, (fat) lactic acid milk, 8 ounces. 
Dextrimaltose, 1 level tablespoonful 
Farina, 2 tablespoonsful. 
Sweet milk, 2 ounces. 
1 egg. 



Lunch 

11 A. 

Dinner 
2 p. M. 



Supper 

6 P. M. 



M. ; 2 per cent, lactic acid milk, 10 ounces. 
Dextrimaltose, 1 level tablespoonful. 

Meat, 2 rounded tablespoonsful. 
Spinach puree, 1 tablespoonful (?). 
Yolk of 1 hard-boiled egg. 
2 per cent, lactic acid milk, 8 ounces. 
Dextrimaltose, 1 level tablespoonful. 

2 large zwieback. 

Cream cheese, li-inch cube. 

2 per cent, lactic acid milk, 10 ounces. 

Dextrimaltose, 1 level tablespoonful. 



9 to 10 p. M.: 2 per cent, lactic acid. 
Milk, 8 ounces. 

Dextrimaltose, 1 level tablespoonful. 
Total calories, 1385; 69 calories per pound. 



Diet III 

For a Very Severe Combined Fat and Starch Case, Three Years Old. Weight 19 

Pounds {Actual Diet Now Being Given to Baby A. B.y 
Breakfast 

7 A. M. : 1 per cent, (fat) lactic acid milk, 8 to 10 ounces. 

Corn syrup mixture, 60 c.c. = 30 gm. carbohydrate. 
Scraped chicken, 1 rounded tablespoonful. 



Lunch 

11 A, 

Dinner 
2 p. Ik 



1 per cent, lactic acid milk. 
Corn syrup mixture, 60 c.c. 



to 10 ounces. 



Scraped chicken, 1 rounded tablespoonful. 
1 per cent, lactic acid milk, 8 to 10 ounces. 
Corn syrup mixture, 60 c.c. 



* This type of diet, containing no starch whatever, is of the utmost value 
in severe starch cases, and gives better results than any other. 



336 PRACTICAL INFANT FEEDING 

Supper 

6 P. M.: Scraped chicken, 1 rounded tablespoonful. 
1 per cent, lactic acid milk, 8 to 10 ounces. 
Corn syrup mixture, 60 c.c. 

10 P. M.: 1 per cent, lactic acid milk, 8 to 10 ounces. 
Corn syrup mixture, 60 c.c. 
Total calories, 1350 (approx.); 61 calories per pound. 

These diets are intended to serve only as a general guide, 
and would naturally have to be modified to suit the individual 
case. As will be noted, they are all high calorie diets, and 
represent the upper limit which a child could take, rather than 
the lower. It will be also noted that sugar has been used in 
rather large amounts in each diet. This is desirable, if possible, 
but often would not be tolerated. In order to get as much food 
as possible into the child it is often well to use a 9 or 10 p. m. 
feeding, as shown on the charts. If this is omitted, the caloric 
value of the diets is, of course, considerably lowered. 

Other Measures of Treatment. — ^Artificial digestants, such as 
pepsin and hydrochloric acid or pancreatin, might be thought, 
from a theoretic standpoint, to be of service. Practically, they 
are of little value. The drugs which may be of service are 
castor oil, bismuth subcarbonate, iron, and tincture of nux 
vomica. Castor oil is often needed, and it is a good plan in 
severe cases to give a dose of it as a routine every week or ten 
days. It should be given especially if the abdomen becomes 
more distended than usual. Bismuth is of value during a re- 
lapse when the stools are frequent and loose. The subcar- 
bonate is the best preparation to use, and can be given in doses 
of 20 grains three or four times a day. Practically aU children 
with chronic intestinal indigestion are anemic; it is therefore 
well to give iron as a routine. The saccharated oxid of iron is 
the most convenient preparation to use, and is given in doses 
of from 3 to 5 grains three times a day. Tincture of nux vomica 
in small doses is of value as a general tonic, and as an appetizer, 
but need not be used as a routine. Needless to say, it should 
not be given if the child were very nervous. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 337 

An intelligent graduate nurse is of the utmost importance if 
the family has the means to afford one. A good nurse soon gets 
to know the child so well that she is of inestimable value to the 
doctor, and these children need some one to care for them who 
can use her head rather than her heart, which is not the case 
if the mother does it. Their lives must be run like clockwork, 
and good results cannot be expected unless an exact daily- 
routine is followed. 

It goes without saying that sunshine and fresh air are indis- 
pensable. Although it is desirable to have these cMldren out 
of doors, it is often best to let them out only once a day, in the 
morning preferably, and to keep them in the house the other 
half of the day, near a smrny open window. This applies espe- 
cially to the winter season, and the reason for it is that they 
are likely to get overtired if they are taken out of doors twice 
during the day, with the incidental dressing and undressing, 
going down stairs, etc. A good many severe cases are too weak 
to walk, in which case they are wheeled when out of doors, and 
allowed to play on the bed or in a pen when in doors. Even if 
they can walk they should not be allowed to take very much 
exercise, as too many calories of their diet are used up in this 
way. They also get overtired very easily. They do well, as a 
rule, in summer, and may gain considerable weight, especially if 
they are at the seashore. There is no place like a sunshiny 
beach for a sick child, and one of my recent patients with 
chronic intestinal indigestion spent practically the whole of 
every day last summer on the beach, with most excellent results. 
In the winter progress is likely to be slower, and a slight cold or 
sore throat may bring about a relapse, and imdo all the good 
that has been accomplished by weeks of painstaking care. 
Massage may be of considerable value in promoting the circu- 
lation. Olive oil is, of course, not absorbed to any appreciable 
extent through the skin, and it therefore makes no difference 
whether alcohol or olive oil is used for the daily rub. 

Course and Prognosis. — The course is long in most cases; it 
will certainly take many months before the child begins to. 



338 PRACTICAL INFANT FEEDING 

even approach the normal. There is no condition which re- 
quires more patience on the part of the nurse, the parents, and 
the doctor, but by persistent effort good results can be obtained. 
Relapses are inevitable, and are manifested by abdominal dis- 
tention, rapid loss of weight, possibly vomiting, and very loose, 
foul movements containing a great deal of mucus. At the onset 
of a relapse the child should be given a dose of castor oil, put to 
bed, and be given for a few days nothing but lactic acid milk to 
eat, with bismuth subcarbonate in large doses. One must not 
try for rapid gains in weight. If the general condition improves, 
if the child looks better, feels better, and is obviously stronger, 
it is well to be satisfied, and not to increase the diet rapidly in 
the hope of bringing about a rapid increase of weight. After a 
few weeks of good stools and better general condition the diet 
can be gradually raised, and finally pushed to the limit. If the 
child is gaining weight and doing well do not change the diet in 
any respect whatsoever, no matter what the calories in it may 
be. With careful treatment the ultimate prognosis is good as 
to final recovery, although it may take two or three years in 
bad cases. When the child finally starts to go ahead he often 
progresses rapidly, and many of these children are eventually as 
healthy as any other children. They are, of course, especially 
during periods when they are not doing well, very susceptible 
to acute respiratory infections, and as a rule bear them poorly. ] 
Milder Cases. — The foregoing applies only to the severe 
type of case, where there is marked nutritional impairment. 
There are, however, many relatively mild cases where the 
nutrition suffers comparatively little, which do not present at 
all the picture of "intestinal infantilism." A child is brought 
because "he does not seem well." His appetite is capricious, he 
is nervous and restless, sleeps poorly, and complains of abdom- 
inal discomfort. The stools may be rather loose and foul, in 
number two or three a day, or they may be constipated, large, 
and of a light gray color, or may appear perfectly normal. 
Upon examination the child is found to be somewhat under- 
weight — the flesh is flabby, the face usually pale, or sometimes 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 339 

somewhat yellowish, with dark circles under the eyes. The 
tongue is likely to be coated, the breath foul, and the urine may 
contain an excess of indican. The abdomen is usually dis- 
tended, but not to the degree that it is in the more severe cases 
previously described. The liver is likely to be enlarged. 

Upon inquiry it will usually be found that the child is being 
overfed either with starch or with fat. The diagnosis is made 
from the symptoms, history, careful scrutiny of the diet, and 
last, but not least, by a microscopic examination of the stools 
for starch and fat. It is in just this type of case that microscopic 
stool examination is of especial value, and indicates at once the 
cause of the trouble. The treatment, in general, is similar to 
that of the more severe cases, but need not be so radical. If the 
indigestion is for fat, it is usually sufficient to pour off all the 
cream from the milk the child is taking, and to omit butter and 
bacon from the diet. Usually, after a few weeks, fat can again 
be added. If the indigestion is for starch, the amount of starch 
in the diet must be considerably reduced, although it is not 
necessary to omit it entirely, as it is in the more severe cases. 
It must be remembered that many children from one to three 
years of age are grossly overfed with starch, taking a large bowl 
of cereal with bread and butter in the morning, potato at noon, 
with more bread and butter, and often cereal and possibly bread 
again at night. It is always advisable in any case of starch 
indigestion, whether mild or severe, to omit potato entirely, as 
this is probably the most indigestible form of starch. Zwieback, 
rice jelly, and farina or barley jelly may be substituted for oat- 
meal and bread, and it is never well to let children have a large 
amount of the same sort of starch during the day. If oatmeal is 
taken in the morning, some other cereal, or milk toast, or zwie- 
back should be taken at night. It is especially important to 
see that all starchy foods are well cooked, and many cases of 
mild or moderately severe starch indigestion arise from a proper 
or insufficient cooking. The prognosis in these milder tj^es of 
indigestion is usually good, and with a little care in the diet the 
child should soon become well again. 



CHAPTER XIV 

THE PHYSIOLOGY, CARE, AND FEEDING OF PREMA- 
TURE INFANTS 

By William W. Howell, M. D., 

Associate Visiting Physician. Infants' Hospital, Boston; Assistant in Pediatrics, 
Harvard Medical School 

Definition of Prematurity. — ^A premature infant, as implied 
by the name, is an infant not yet fully developed. The name 
is applied to an infant in every respect normal except that it 
has been born before it is fully developed in some of the funda- 
mental capacities fitting it for this life. The pregnancy for one 
reason or another has terminated early and the baby is born in 
an unripe state. The term "prematurity'' is often erroneously 
used as synonymous with weakness or debility. Prematurity 
means premature birth and needs no other explanation. Con- 
genital debility, on the other hand, means a deficiency of vital 
energy and a lowered resistance irrespective of the age. The 
confusion comes in that at times a premature may be debili- 
tated as well as born too soon. It was well expressed by Tarnier, 
who said, "Not all premature children are weaklings, and not 
all weaklings are premature." Hence we may speak of a baby 
as mature, born at full term; premature, born before full term; 
inmaature, a weakling irrespective of age. 

That all prematures are feeble as compared to healthy in- 
fants born at term must be evident, and it is a great mistake to 
judge a premature by the development of the full-term infant 
as a standard for normal. The premature may or may not be 
normal for his own age, but what is normal for seven months is 
abnormal for eight months as well as for full term. One might 
say that a premature is an unripe individual, and for that reason 
340 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 341 

unprepared for the difficulties of the life of the full-term baby. 
A knowledge of the reason of the early birth and of the degree 
of the unripeness is essential, for in the recognition of his unfit- 
ness lies the cure for the treatment of a premature. It is unwise 
to be too sanguine as to the general appearance of a premature. 
If an infant is born before term it is unripe, unfit, and must 
be treated according to its age. The old idea that a baby born 
at seven months has a better chance than one born at eight 
months is wrong. The eight months* premature looks like a 
full-term infant and is, in consequence, given care without con- 
sideration of his deficiencies. Of course, the earlier born, the 
greater the difficulties in treatment, but if there is any question 
as to the length of the pregnancy, treat the baby as a premature, 
if only for a few days, regardless of its appearance of maturity. 

Incidence. — ^The incidence of prematurity varies as reported 
from different sources, and is estimated as high as 5 to 25 per 
cent, of all births. The variable figures must depend on the 
factors causing early births, and are probably more active at 
one time or place than another. During war or any great social 
upheaval, with the attendant nervous strain, insufficient nutri- 
tion, and the whole disorder of living, the mothers are probably 
in such condition that they are unable to go to term. During 
epidemics of infectious diseases the rate of prematurity increases. 
The greater percentage of premature births mentioned in the 
winter and spring months as compared to summer and fall is 
very likely due to infection and unhygienic conditions. 

Causes of Prematurity. — Premature interruption of the preg- 
nancy is spontaneous, or induced by reason of obstetric neces- 
sity, and the causes leading to the early birth may be grouped 
under six general heads. These causes are: (1) External, as 
physical exhaustion, lifting, nervous excesses; (2) trauma, with 
rupture of the membranes; (3) multiple pregnancies; (4) faulty 
nutrition; (5) disease in mother and baby (syphilis); (6) disease 
in the mother, cardiac and kidney, tuberculosis; acute infec- 
tions, as scarlet fever, influenza, typhoid, measles, pneumonia, 
and the toxic poisons of alcohol, phosphorus, mercury, and 



342 PRACTICAL INFANT FEEDING 

morphin. Some of these are not only the causes of prematurity, 
but make for debility as well, so that a baby born before full 
term of a diseased or enfeebled mother is probably feeble as well 
as premature, especially if the fetus suffers the infection. 

Physiology. — The most troublesome factor in the successful 
management of a premature is his unstable heat regulation. 
This is dependent on three reasons: increased radiation, un- 
stable heat regulation, and lowered chemical heat production. 
The premature radiates heat more easily for two reasons — ^poor 
fat pad to conserve heat, and relatively greater radiating sur- 
face compared to his cubical contents, which means heating 
plant. The nervous system is underdeveloped, including the 
heat center; hence the premature is unable to prevent the loss 
of heat. It is true that a premature loses heat after birth and 
has no power to regain it unless heat is supplied artificially; 
while, on the contrary, a full-term baby loses heat and has the 
power to regain it. It is equally true that the premature can- 
not prevent getting overheated if the surroundings are at too 
high a temperature, which often is as disastrous as chilling. 
Added to the conservation and regulation of heat is the third 
reason of imstable temperature, and that is the poor chemical 
heat production due to low powers of digestion and metabolism. 
There are at times other reasons given besides the three men- 
tioned, which are unimportant, and, as a matter of fact, are 
merely slight contributory causes. 

The nervous system is quite unstable and the control of the 
vital nerve centers poor, owing to the fact that some of the 
nerves are still unmeduUated and the nerve centers undevel- 
oped. In consequence of this undeveloped nervous system pre- 
matures are sluggish in their reactions: they are somnolent and 
inactive; their movements are slow, and the cry feeble. They 
are prone to intracranial disturbances, such as cerebral hemor- 
rhage and hydrocephalus of the oversecretive type, which, for- 
tunately, tends to spontaneous cure. 

The heart and circulation show underdevelopment. Dur- 
ing the last few weeks of intra-uterine life the ductus arteriosus 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 343 

narrows, thus aiding its postnatal closure, arid also of the for- 
amen ovale. The heart is surprisingly strong and regular in 
action, but occasionally due to faulty innervation may show- 
weakness and irregular action, with cyanosis and edema. The 
blood-vessels are fragile and hemorrhage may occur from slight 
causes. 

The blood shows more of the fetal characteristics the earlier 
the birth. As a rule the coagulability is low, hemoglobin and red 
cells high, and there are many nucleated cells. The H ion con- 
centration is higher than in normal full- term babies. Behrend 
showed that in the first few days of life the alkalinity was only 
70 to 80 per cent, that of the adult, but increases rapidly with age. 
Pfaundler attributes the greater susceptibility to infection to 
the high H ion concentration, as it has been shown that dimin- 
ished H ion concentration gives greater resistance to bacterial 
invasion. It is proper to mention here that there may be an- 
other reason for increased susceptibility to infection in the lack 
of antibodies received into the blood from the mother. Pre- 
matures early become anemic on account of their poor blood- 
making power, the greater blood destruction, and the deficient 
supply of iron. 

The respiratory system shows marked lack of nervous con- 
trol. The breathing is shallow and irregular, and there may be 
long pauses when no apparent air exchange takes place. As a 
result of the unstable nervous control expansion of the lungs is 
poor, atelectasis is common, and metabolism cannot be perfect. 
There may be frequent attacks of cyanosis, rapid breathing, and 
asphyxia, and such an attack may be fatal at any time during 
the early weeks of life though the baby seems to be doing well. 
These attacks are variously explained. Finkelstein believes 
they are caused by carbonic acid intoxication aided by insuffi- 
cient lung expansion due to abdominal distention. Budin says 
they are due to underfeeding and disappear with forced feeding. 
Other writers think they are due to cerebral disturbance, pul- 
monary atelectasis, or aspiration of milk into the trachea, and 
that owing to poor reflex action the babies are unable to cough 



344 PRACTICAL INFANT FEEDING 

out the food. I have seen several with cyanosis and rapid breath- 
ing due to enlarged thymus. At all events there must be several 
causes for such attacks, and obviously the treatment depends on 
the cause. 

It is natural that the digestive tract should share in the lack 
of development. The very young prematures often do not know 
how to suck or swallow, and older ones may know how, but soon 
tire. Not only is the mechanical part of the work deficient, but 
the chemical as well. The digestive juices are quantitatively 
and qualitatively low. They can take care of all of the food 
elements, including starch, to a limited degree. The digestion 
is weak, yet the premature needs more food than older infants 
to give him the required fuel, to make up for the unstable heat 
regulation, and to supply the materials for more rapid growth. 
The caloric requirements are variously estimated at from 120 
to 180 calories or even higher per kilo. The lowest figures are 
much above those given as sufficient for a full-term baby. Ober- 
warth found that the average quantity of milk taken by 33 pre- 
matures at fifty-one different nursing periods during three months 
was 63 calories per pound. It is stated that an infant needs 
one-sixth of its body weight in fluid per day. These figures for 
food and fluid are impossible to get in the first few days, but 
must be approached as soon as possible, especially as regards 
fluid, in order to prevent the storing up of waste products and, 
hence, inanition fever. These babies are poor nursers, and if 
by chance strong enough to go to the breast, they must be 
watched to see that they get sufficient food and fluid. If the 
breast secretes well, they may be overfed, but, as a rule, they are 
so feeble that to get enough it may be necessary to put a strong 
baby to the other breast at the same time or express milk while 
nursing. The initial loss of weight should be relatively less than 
of the full term, as there is less meconium and food and fluids 
are started earlier. On the other hand, the gain is slower— an 
average of | ounce daily and 4 ounces a week is satisfactory. 

Though the kidneys begin to function in the late fetal months, 
they do so rather imperfectly. In consequence of the poor 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 345 

kidney action and the insuflScient intake of fluid the urine is 
scanty, the acidity high, and there may be enough uric acid to 
cause infarction, with temporary suppression. The proportion 
of ammonia nitrogen to total nitrogen is less than the normal, 
while the non-protein nitrogen is increased, indicating an in- 
crease in the decomposition processes. 

Resistance to infection is poor and infections, no matter where 
the portal of entry, are likely to be severe or at least more severe 
than in older babies with the same type of disease, and may run 
a course with high or low temperature. There is a virulent, 
hemorrhagic form of pneumonia which runs an afebrile course. 
It is not possible to rule out an infectious process in a pre- 
mature because of a low temperature. This low resistance has 
been explained, as mentioned above, on the grounds of the 
higher H ion concentration of the blood. 

The weight of the premature depends on the age and the 
cause of the early birth. As there are factors outside of the age 
which have a bearing on the weight, the age cannot be deter- 
mined from the weight alone. From the figures of Berthod, 
48 babies born at eight months or more, including 7 at term, 
the average weight was 4i pounds; 52 born at eight months or 
less, including 2 at six months, the average was the same, 4| 
pounds. The weight varies from 2 to 5i pounds, hence, if under 
5 pounds and not puny, an infant is probably premature. Natu- 
rally, if born of a healthy mother and not born early by reason 
of disease, the baby will be heavier than one of the same age 
born of a diseased or enfeebled mother. 

The development of the skeleton gives some evidence not 
only in its measurements but also from roentgenograms of the 
centers of ossification. During the late months of intra-uterine 
life the lower extremities grow rapidly as compared to the upper 
half of the total length. The premature is short, especially in 
the lower extremities, as compared to the upper half, giving a 
total length of 19 inches or under. The circumference of the 
head is always greater than that of the chest. There have been 
tables worked out giving measurements for different ages and 



346 PRACTICAL INFANT FEEDIN( 

weights, but for all practical purposes a baby of 19 inches or less 
is presumably premature. 

The skin is red, wrinkled, as there is very little subcutaneous 
fat, covered with lanugo hairs, dries and macerates easily. The 
ears lie as tabs close to the head. The nails may be absent or, 
if present, thin and fall short of the ends of the fingers. Icterus 
neonatorum is usually well marked and may be slow in clearing. 
Feeble prematures not uncommonly show sclerema. 

Prematures are poorly supplied with mineral salts (especially 
iron) which are stored up in the late weeks of intra-uterine life. 
Hugounenq's analyses indicate that twice as much mineral salts 
are stored up in the last three months as in the first six. Hence 
it would appear that the more premature the birth, the less 
salts and iron the infant will have, and, of course, the earlier will 
the stock be exhausted. It is true that premature babies show 
anemia and rickets much earlier than full-term babies. Hue- 
nekens found definite rickets in 27 of 33 prematures seen for the 
first time when four months of age, which is earlier than is usually 
found in normal full- term infants. 

We may sum up the characteristics of a premature as follows: 

he is small, emaciated in the sense that he has no subcutaneous 

fat; skin red, wrinkled, covered with lanugo hairs, head large 

compared to the chest, limbs small and puny, nails thin and fall 

short of the ends of the fingers, cry feeble, torpid and hard to 

waken, eyes kept closed, respiration superficial and irregular, 

temperature low, with a tendency to fall and hard to maintain 

at the normal level, power to suck and swallow diminished or 

absent. 

TREATMENT 

General Care. — The fundamental principles of the care of 
premature babies are plain, and the treatment should be simple 
and easy to carry out. The whole plan of treatment is based on 
the endeavor to supply what is lacking and make up for defi- 
ciencies. It is made difficult in that often we make our machinery 
for the care too complicated, depend on mechanical devices to 
spare brains, whereas the successful result depends upon simple 



PHYSIOLOGY, CARE, FEEDING OF PREMATUEE INFANTS 347 

procedures and simple apparatus watched over by an intelligent, 
interested, and faithful nurse. 

For the purposes of treatment it is important to determine 
two things about a premature— its probable age and its vigor. 
All things equal, a vigorous baby of eight months has a better 
chance than a vigorous one of seven months, but, on the other 
hand, the older baby, even though somewhat feeble, with care 
has a better chance than the yoimger one, for he is more mature 
and functions better. The age is to be determined from the 
history of the pregnancy, from the weight, and from the total 
length. The vigor is to be judged from the weight, temperature 
behavior, cry, condition of the respiratory apparatus, and other 
signs of feebleness. 

The premature lacks energy, vitality, stability. No matter 
how strong he may appear, he is to be treated with greater care 
than a more feeble full-term baby, for he is unripe and unpre- 
pared. He has no business to be out in the world, consequently 
the expert care or, rather, intelligent care should begin with the 
first breath. Many prematures have been lost for lack of care 
in the period after delivery when received in a cold blanket, 
and tucked away anywhere to be out of the way until a more 
convenient time arrives to fix them up. In the meantime too 
much heat has been lost. Heat should be supplied immediately, 
unnecessary handling prohibited, and no examination made that 
can be avoided. They should not be transported, but if unavoid- 
able and impossible to keep where born, should be carried in a 
heated basket protected from cold air. A premature is better 
kept in any fairly ventilated, warm place than rushed out in the 
cold or storm to a model hospital. Let him alone, do not handle 
him when possible to avoid it, and keep all inquisitive persons 
away, because they may fuss and handle the baby and bring 
infection. 

At the confinement there should be some person delegated to 
care for the baby, someone having no other duties than to take 
charge of the baby and start the premature care at the first 
moment. If it is etherized or not breathing well it may be wise 



348 PRACTICAL INFANT FEEDING 

to keep it in a warm bath until breathing well, and if at any sub- 
sequent time the temperature is low in spite of heaters, put the 
baby in a warm bath until the temperature is up. As soon after 
birth as is deemed wise oil it, put on a gown, and place it in a 
suitable bed in a warm place. 

I feel that there is no necessity for complicated electrically 
heated beds and premature roomr. Incubators should be men- 
tioned only to condemn them. Electric pads are dangerous when 
tucked in the bed under the clothes from the possibility of fire, 
and from steam if wet. Of course, the fire danger does not apply 
to beds heated by electricity. My objection to complicated 
beds is that they are expensive and are unnecessary for ordinary 
family use, and even in hospitals I have found the ordinary 
infant crib perfectly satisfactory when dressed in such a way as 
to make a premature bed. 

A workable premature bed can be made out of any large 
basket or wire infant crib. The sides should be lined by a pad- 
ding made of silence cloth, such as used on dining tables, or thin 
blanket covered with cotton sheeting. This padding is carried 
about the four sides of the bed and under the hair mattress, 
covered with rubber or stork sheeting. Thus cold air is pre- 
vented from coming up about the baby. The bed is then covered 
head and foot with sheets or curtains which extend over the 
sides, leaving an air space between the edges of the head and 
foot curtains about a third of the distance from the head of the 
bed to the foot. This air space may be narrow or wide, according 
to the needs of the baby. 

The room should be light, airy, and easily ventilated. The 
premature baby's eyes must be protected from strong light, but 
that is no reason why the room should not be hygienic. I have 
been in premature rooms presumably properly constructed as to 
heat and moisture regulation, but with air so foul that a few 
minutes stay was enough to give one a headache. The tempera- 
ture of the room should be as little above 72° F. as possible. 
However, much higher temperature, even to 80° F., may be re- 
quired. In the climate of Boston there is no need for concern as 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 349 

to the moisture, but in dryer climates the humidity must be 
watched, for the babies do not do well and have dry skin and 
cracked lips if the humidity is low. 

The most troublesome factor in the management of a pre- 
mature is the heat regulation. As has been mentioned, this is 
dependent on the lack of the fat pad to conserve heat, increased 
radiation, and deficient heat supply. The fat pad is supplied 
by a padded gown, increased radiation is prevented by the 
gown, heat is supplied by a padded bed, heaters, and warm air 
to breathe. It may be difficult at first to adjust the arrange- 
ments so that the temperature will stay at the normal level of 
99° to 99.5° F., though the sooner this is accomplished, the more 
promising the outcome for the baby. 

There are several types of gowns, and all have good points. 
The simplest pattern is a rectangular body part with a small 
square fastened at the middle of the top, which, when folded 
and sewed together along the top edge, makes a hood. A cheap 
gown is made of cheese-cloth, padded with non-absorbent cotton 
and quilted. Better gowns are made of eiderdown, which, 
though more expensive to make, are, as a matter of fat, cheaper 
in the end, for they can be laundered, whereas the cheap cotton 
gown must be thrown away when soiled. The body part should 
be wide enough to wrap about the baby, with plenty to pin, and 
long enough to turn up and pin. The gown may be fastened 
together with tapes instead of pins if desired. 

As soon after the birth as possible the baby is oiled with sweet 
oil or mineral oil applied with absorbent cotton rather than with 
the bare hand, for cotton is softer and less likely to irritate the 
skin. A shirt should be put on, especially if eiderdown gowns 
are used, the usual cord dressing applied, and a diaper with a 
square of absorbent cotton under the buttocks which will stay 
in place without pinning. The gown is then fastened, and out- 
side of all is wrapped a blanket. This whole bundle — of baby, 
gown, and blanket — is placed in the premature bed with three 
hot-water bottles, one on each side and one at the foot. On the 
front of the blanket wrapped about the baby is laid an ordinary 



350 PRACTICAL INFANT FEEDING 

bath thermometer. Over all — baby, thermometer, and bottles 
— the ordinary blankets are placed and tucked under the mat- 
tress. The best heaters are some form of stone hot-water bottles 
or jugs. We are able in Boston to get very satisfactory old- 
fashioned stone hot-water bottles made by the Dorchester Pot- 
tery Company. These stoneware heaters are better than rubber 
or metal bottles, as they radiate heat more slowly and stay hot 
longer. The water should be distinctly warm to the wrist, a 
temperature of about 115° to 120° F. The heaters should never 
be changed all at one time, but in rotation, thus endeavoring 
to maintain a uniform temperature. 

The bath thermometer on the outside of the wrapping 
blanket and under the covering blanket is the guide to the 
management of the bed heaters, ventilation, and room tempera- 
ture. The rectal temperature should be taken every four hours 
for the first three days, or until the baby's temperature runs at 
the normal level of 99° F., or, better, a little above, and it is 
nearly impossible to obtain good results with feeding unless the 
temperature runs properly. Frequent readings of the bath ther- 
mometer ought to be made to observe what temperature it re- 
cords when the baby is normal. This is the guide — the tem- 
perature of the bath thermometer — as to the temperature of the 
room and the heaters, which should be kept at whatever tem- 
perature is necessary to keep the bath thermometer at the 
established point. A good starting-point for the bath ther- 
mometer is 85° F., which is to be lowered or raised according to 
the needs of the baby by more or less frequent changing of the 
heaters or varying the temperature of the room. I think it will 
be obvious that the arrangement of the bed thermometer gives 
a convenient indicator as to the proper temperature without dis- 
turbing the baby more than twice a day for a temperature 
taking. 

The baby is not to be handled or in any way disturbed more 
than is absolutely necessary. The gown is opened twice daily 
after the first three days or after the period of four-hour tem- 
peratures, when the diaper is changed and a rectal temperature 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 35 1 

taken. At other times it is only necessary to remove the ab- 
sorbent cotton square unless the diaper is wet. Every third day 
the baby is to be taken out of the gown, oiled, weighed, and a 
fresh gown put on. Once a day the face and buttocks should be 
washed with soap and water, and, as a rule, no other bathing 
until the baby is out of premature care. Occasionally a baby 
with tender skin cannot stand oiling and a heavy gown, and the 
axillary regions will become macerated. This necessitates the 
use of powder and a thin gown, in which case the surroundings 
must be at a higher temperature. 

Feeding. — In a choice of foods breast milk stands alone. 
The older babies do better with breast milk, the young, feeble 
ones must have it, at least in part. The problem of feeding is 
simple if there is a good supply of breast milk, and then it is 
only a matter of how to get the food in, the quantity at each 
feeding, and the intervals between feedings. I think a safe rule 
to follow is never to put a supposed premature to the breast 
\mless it is vigorous, and not until a few days have elapsed, in 
order to judge of his vitality, and even then with caution for fear 
of overtiring. Prematures are not strong enough nursers to 
stimulate the breast. They may for a short time pull well, and 
it is sometimes surprising how vigorously a little premature will 
pull on the breast. I have seen a feeble premature pull the nipple 
into a nipple shield, but they must be watched, as the exhaustion 
can easily more than make up for the amount of milk obtained, 
and failure to gain be due to overexertion at nursing. However, 
underfeeding is not the only danger in breast feeding, but, on the 
contrary, there is the danger of overfeeding if the milk flows 
abundantly. The nerve reactions of a premature are feeble and 
he does not know when he has had enough, and must, of neces- 
sity, regurgitate when overfull. Vomiting or regurgitation are 
signs of danger in feeding prematures, which must never be 
ignored whether the feeding is natural or artificial. Regurgita- 
tion is the first sign of indigestion, and the food must be lowered 
in quantity or quality, or both. 

Fluids should be given a few hours after birth, plain water or 



352 PRACTICAL INFANT FEEDING 

5 per cent, solution of sugar of milk, in teaspoonful doses, in- 
creased rapidly by | teaspoonfuls till the baby refuses or regur- 
gitates. This will depend on the ability to suck and swallow. 
Fluids must be given, and if the baby can neither suck nor swal- 
low, he must be tube fed; if he can swallow, use a medicine- 
dropper, spoon, or Breck feeder; if he can suck and swallow, 
Breck feeder, bottle, or breast. An ordinary urethral catheter, 
size No. 12 French, with a small funnel attached either directly 
into the catheter or by a rubber tube and glass connection 
(the glass part of a medicine-dropper does well) affords a satis- 
factory tube for feeding. Introduce the catheter just beyond 
the pharynx, as manifested by the gagging reflex, or if this not 
present, to about 4 inches beyond the lips. It is not necessary 
to push the tube into the stomach. Feed slowly and inter- 
mittently by pinching the tube, and do not overfill the stomach. 
The Breck feeder is made on the plan of a large medicine-dropper 
with a small nipple on the small end. The glass part holds an 
ounce and is drawn down at one end to fit into a nipple the size 
of the rubber of a medicine-dropper, and at the other end is a 
rubber bulb shaped like a big finger-cot. Pressure can be made 
on the bulb to aid a baby with feeble sucking power. 

There seems to be some difference of opinion as to the inter- 
val between feedings. I have no s)rmpathy with the long four- 
hour interval. Except with a tube I do not see how it can be 
possible to get in a sufficient amount at each feeding to cover 
the requirements for the day. I believe with two-hour intervals 
night and day for the first few days it is easy to get in the total 
requirement without undue strain on the baby. They will not 
take much at first and frequent feedings are necessary. As 
soon as possible I lengthen the interval at night and then in the 
day. When the weight is 5 pounds and the baby doing well, 
three-hour day feedings and four-hour night are better, for the 
total requirements can be met and the baby disturbed less 
often. I usually begin with 1 dram and increase by | dram every 
feeding or every other feeding until the tolerance is reached. 
It has seemed to me best to find out the quantity of water or 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 353 

weak food tolerated first, and then to increase the quality. It 
is far better to feed a sufficient quantity of weak food than to 
cause an indigestion with a small quantity of strong food. 

I should never consider any other food than breast milk ex- 
cept from necessity. It should be diluted as low as one-third 
breast milk and two-thirds water, or lime-water, depending on 
the age and vitality of the individual premature. Increase the 
strength as rapidly as seems prudent. It is not possible to lay 
down rules for the routine feeding of prematures any more than 
can be done for older babies; each must be fed as an individual 
and his individual needs considered, and the food made to 
conform to those needs. After the mother's milk comes it is 
often safe to put the baby to the breast twice a day for a few 
minutes, gradually increasing the number of nursings until it is 
entirely breast fed. In the meantime express or pump the 
mother's breast for the whole or part of the supply for the bottle 
feedings. This can be done for months, and I have had mothers 
carry their babies through the entire nursing period on their 
own drawn breast milk when it was impossible for reason of in- 
ability on the part of the mother or baby to nurse at the breast. 
A little breast milk either nursed or drawn is far better than 
none. 

For artificial food I prefer whey mixtures. A safe starting 
mixture is 1 per cent, fat, 5 per cent, carbohydrate, 0.50 per 
cent, whey protein, and 0.25 per cent, casein. Such a mixture 
is made of IJ ounces of gravity cream taken from all the cream 
removed from the top of an ordinary bottle of milk after stand- 
ing six hours, 10 ounces of whey, H level tablespoonfuls of sugar 
of milk, boiled water up to 20 ounces. The whey must be 
heated to 145° F. to kill the rennin, otherwise the casein of the 
cream will be coagulated and tend to plug the nipple. This 
mixture can be increased by the addition of cream and whey as 
desired. It has been my experience that prematures tolerate 
fat well, but that high sugar foods start carbohydrate fermenta- 
tion and indigestion with secondary fat intolerance, and that 
high proteins putrify, causing colic and poor appetite. The 
23 



354 PRACTICAL INFANT FEEDING 

mixtures should be well balanced, with protein enough to cover 
the requirements and no more, and with fat and carbohydrate 
to make up food sufficient for gain in weight or to cover the sup- 
posed caloric needs. Such mixtures cannot be made of whole 
milk dilutions. Though some young babies stand whole milk 
dilutions, my most troublesome feeding cases in young babies 
and prematures have been those previously fed on mixtures 
too high in protein with consequent protein putrefaction. When 
the protein needs cannot be covered by a whey mixture, change 
to total protein mixtures made after any fashion desired by the 
attendant. The baby is no longer premature in its feeding prob- 
lem and can be fed as an older baby. 

The time to consider a baby no longer premature is when he 
can take care of his own temperature. If the temperature runs 
above normal, supply less heat by removing one or all of the 
heaters. Next take off the gown, dress in ordinary clothes, and 
put back the heaters. Finally, dismantle the bed. The gradual 
change from premature care is brought about by the tempera- 
ture behavior, and when the temperature remains normal with- 
out extra heat, the baby is to be treated as an ordinary baby. 

Prognosis. — All figures of prognosis as given are misleading, 
for the feeble babies are not separated from the true prematures, 
that is, normal babies born before full term. Hence the prog- 
nosis of a premature must depend on what he is and what he 
does. In general, the younger or earlier the birth, the more 
uncertain the prognosis. Potel gives the following figures for age: 

56 babies born at 6§ months, 83 per cent. died. 
131 babies born at 7 months, 58.1 per cent. died. 

53 babies born at 7^ months, 30. 1 per cent. died. 
110 babies born at 8 months, 35.5 per cent. died. 

The weight comes second. Crede's figures show a very large 
mortality among the very small babies, which probably include 
many debilitated ones. His figures are: 

2| to 3 pounds, 83 per cent. died. 
3 to 4| pounds, 36 per cent. died. 
4| to 5| pounds, 11 per cent. died. 



PHYSIOLOGY, CARE, FEEDING OF PREMATURE INFANTS 355 

The cause of the early birth is very important. If premature 
by reason of disease, which means debility as well as prematur- 
ity, the prognosis is grave in proportion to the debility. Com- 
plications of atelectasis, hemorrhage, sclerema, and infections 
certainly add to the danger and make the prognosis hopeless. 

The figures of 144 prematures at the Infants' Hospital may 
serve to bring out some of the points in support of the early care 
and of the prognosis. Of the total number when last heard of, 
51 were living and well. The remaining 93 died, some lived just 
long enough to enter the hospital, some died after leaving the 
hospital, as long as ninety-nine days after birth. Of the 93 that 
died, 36 died the first day in the hospital. The largest single 
factor in these 36 was delay in instituting proper early care, and 
the next factor was loss of heat from transportation. Of the 
remainder of the 93, or 57 in all, 2 died of congenital syphilis^ 
2 of congenital heart disease, 10 of pulmonary atelectasis, and 
43 of infections, some of these after leaving the hospital. The 
average weight of the 57 that died was 1659 grams. The average 
weight of the 51 living was 1864 grams. The smallest of the 
living was born at six and a half months and weighed 1010 grams, 
about 2i pounds. 

Naturally, the most important point in the prognosis, if the 
baby is normal, is the care. I believe the largest single factor in 
the high mortality of prematures is the failure to begin treat- 
ment at the proper time — the moment the baby is born. A 
normal premature of seven months, kept warm, fed properly, 
and not handled, has a good chance, and will develop so that at 
the end of a year he has caught up to a full-term baby of the 
same age. 



CHAPTER XV 
CONSTIPATION IN INFANCY 

It is normal for a baby fed on cow's milk to be slightly con- 
stipated, probably largely on account of the relatively high 
calcium and casein content of cow's milk. In many cases the 
constipation may be so great as to be abnormal, and is a great 
source of worry to the mother, but rarely gets the baby into 
any serious trouble. 

The cause Hes usually rather in the food than in the baby, 
but the relatively thin musculature of the infant's intestine 
also partly accounts for it. Furthermore, babies who are atonic, 
anemic, and flabby, usually also have atonic intestines, with 
sluggish peristalsis. The constipation in these babies usually 
improves coincident with improvement in nutrition. Underfed 
babies may be constipated, owing to the fact that the absorption 
of food is so complete that there is little left to make a fecal 
residue. Babies fed on whole milk mixtures, with the addition 
of a small amount of carbohydrate, are more Hkely to be con- 
stipated than those who are taking a food rich in fat and sugar 
and low in protein. Starch, when it is poorly digested, some- 
times tends to make a dry, bulky, constipated stool, provided 
that it has not fermented. Babies fed on malt sugar prepara- 
tions containing a high dextrin content are more likely to be 
constipated than those fed on lactose or on a malt preparation 
containing more maltose. 

Constipation is not pathologic unless the baby goes for more 
than forty-eight hours without a movement, or unless it is giv- 
ing him sjmiptoms. If the stools are very large, as in cases of 
chronic fat indigestion with soapy stools, he may not have 
strength enough to force them out. If so much of the food is 

356 



CONSTIPATION IN INFANCY 357 

absorbed that no stimulating products are left behind to pro- 
mote peristalsis, the stools become very hard, dry, and scyb- 
alous, and large amounts may collect in the rectum and lower 
part of the colon. These become still further dried out, and it 
may be impossible for the baby to pass the marble-like scybala 
imless an enema is given to soften them. For constipation 
such as this laxatives do little good. With scybalous stools 
there is a good deal of pain on defecation and often slight streaks 
of blood on the outside of the stool. There is also likely to be 
considerable abdominal distention owing to the backing up 
of gas, with symptoms of discomfort from this source. Con- 
stipation, unless associated with actual intestinal obstruction, 
such as intussusception, rarely causes vomiting, nor does it 
impair the nutrition of the child unless of the fat-soap stool 
type. It causes more worry to the mother and discomfort 
to the child than it does serious trouble. 

A baby should be trained early to pass his stools at a regular 
time. The sixth or seventh month is not too early to begin. 
He is held upon a vessel, with a good support for his back, and 
a small greased glass rod or a glycerin suppository is inserted 
in the rectum. This will usually be followed by a stool, and 
after this procedure has been continued for a week or two, 
many babies realize that they are expected to make a stool 
at this time, and will usually do so. 

Treatment of Constipation. — Food, — ^A regulation of the 
food is of the greatest importance. The sugar is the most im- 
portant element in this connection. If the baby is on a food 
low in sugar and high in protein, adding lactose and reducing 
the protein will often accomplish the desired result. Some- 
times the addition of 1 or 2 tablespoons of lactose to the day's 
feeding is all that is necessary, and the sKght lactose residue 
which is not absorbed is fermented, the stimulation of which 
is just enough to correct the constipation. The use of a liquid 
malt preparation is almost always followed by good results, 
and is the most valuable single measure at our command in 
the treatment of constipation in infants. About 2 table- 



3S8 PRACTICAL INFANT FEEDING 

Spoonfuls a day, added to the day's feeding, is usually enougk. 
If this does not suffice, enough shoidd be used to attain the 
desired result. In babies over eight months of age the addition 
of a tablespoonful of strained spinach or carrots to the diet is 
often productive of good results. A small amount of prune 
juice or apple-sauce may be used even before this. Orange 
juice has only very slight if any laxative action in most babies, 
and can never be relied upon. 

Drugs. — In many cases laxative drugs are necessary for a 
time while the food is being adjusted, and help a good deal, 
although, of course, they do not cure the condition. Milk of 
magnesia is probably the best mild laxative for babies, and is 
the one most generally employed by the laity. A teaspoonful 
once a day, given in the milk, usually suffices. Another drug 
which is of value, especially in babies over one year of age, is 
casafru, a preparation made from the pods of the senna plant. 
It is very mild in its action, and babies take it readily. A tea- 
spoonful given at bedtime is the usual dose. Castor oil should 
not be used in the treatment of constipation; it is a cathartic, 
not a laxative, its after-effects are somewhat constipating, and 
it should be used only when it is desired to empty the intestine 
quickly and thoroughly for some special purpose, as in the 
onset of a diarrhea or an acute infection of any sort. 

Suppositories and Enemata. — Suppositories are often of 
value where the rectum is sluggish, and where the baby needs 
some such stimulus in order to induce him to go through the 
motions of having a movement. They are, of course, of no 
value in constipation due to a sluggish upper intestine. Their 
continued use is a bad habit, as it is likely to accustom the 
baby so to them that he will not attempt to have a movement 
unless one is used. They may in some cases, also, be irritating 
to the rectum, and they not infrequently cause a proctitis, 
sometimes of severe degree. 

In obstinate cases of constipation the use of enemata is the 
best method of emptying the bowel, especially when there may 
be a large fecal mass either low in the colon or in the rectum 



CONSTIPATION IN INFANCY 359 

SO hard and large that it cannot be passed. If the scybala 
are very hard an oil enema may be necessary, to leave in the 
rectiun over night, and to be followed in the morning by a soap- 
suds enema. 

Enemata made of soapsuds and water are usually sufficient, 
and it is not necessary or advisable to use anything stronger 
in babies. I much prefer the large douche bag with a small 
nozzle to any of the smaller syringes which are so often used, 
as in order to secure results it is sometimes necessary to give a 
large amoimt. 



CHAPTER XVI 

HABITUAL LOSS OF APPETITE 

Habitual loss of appetite is fairly common in oabies from 
six months to a year old, very common in older children, and is 
often a most annoying and difficult condition to treat. Babies 
under six months rarely lose their appetites. Let us consider 
first babies fed on milk exclusively, second, older children who 
are taking a mixed diet. The ordinary causes of habitual loss 
of appetite in small babies are: 

L Teething. 

2. Overfeeding with fat or sometimes sugar. 

3. Beginning rickets or scurvy. 

4. Not enough fresh outdoor air. 

5. Too frequent feeding. 

Many babies eat poorly as soon as they begin to feel the 
first teeth, particularly the upper ones. There may be nothing 
noteworthy to see in the mouth except very slight swelling of 
the gums, and the teeth may not come through for several 
weeks. The pressing of the nipple against the gums causes just 
enough discomfort to make the baby disinclined to suck. 
There is not much to do for loss of appetite connected with 
teething, except to keep the baby outdoors as much as possible, 
to try spoon feeding instead of bottle feeding, which is usually 
not very satisfactory, and to lance the gums if they are very- 
much inflamed, hot, and tender. Many babies who are overfed 
with fat eat poorly; indeed, loss of appetite is one of the earliest 
and most important symptoms of beginning fat indigestion. 
The treatment is to feed the baby on a fat-free milk for two or 
three weeks, until his appetite returns, when fat may be grad- 
ually added again. This is often very efficacious, and a baby 
will often take twice as much of the fat-free food as he did of 
the other. 
360 



HABITUAL LOSS OF APPETITE 36 1 

Occasionally an excessive sugar intake will cause loss of 
appetite, and may be attended with no symptoms of sugar 
indigestion. Usually cutting down the amount of sugar causes 
improvement, or sometimes changing the kind of sugar in the 
modification is of benefit. 

Babies with beginning rickets often eat poorly. Fresh air 
and sunshine, cod-liver oil, and the substitution of beef juice, 
soups, cereal jellies, and vegetable purees for a part of the milk 
in the diet helps in most cases. If a latent or subacute scurvy 
is suspected, orange juice will usually improve the appetite. 

Now-a-days most mothers realize the benefit of fresh out- 
door air for their babies, but some mothers who have no nurse- 
maids are so busy with household cares that they are able to 
take the baby out not at all in the morning, and only for a 
short time in the afternoon. Babies who do not get out much 
often do not eat well, no matter on what sort of food they are 
fed. If it is not possible for the mother to get the baby actually 
out of doors enough, he can be dressed as if to go out and put 
near an open window, preferably the sunniest one in the house. 
The present custom in almost all new houses and many apart- 
ment houses of having sun porches is a good one as far as the 
baby is concerned, and I have known babies who have never 
been taken on the street at all, but who live, eat, and sleep upon 
the Sim porch, with the windows wide open, which is just as 
good as going outside. 

Babies under five or six months of age will usually eat, no 
matter how often they are fed, but too frequent feeding inter- 
vals is a fairly common cause of loss of appetite in older babies. 
By too frequent intervals I mean any interval of less than three 
hours, and, indeed, a good many babies after the eighth month 
do better on the four-hour interval. In increasing the interval 
between feedings for a baby who has lost his appetite it must 
be remembered that it is the twenty-four-hour amount he takes 
which is important, and not the amount at each individual 
feeding. So that if he takes only a little more at each feeding 
when fed every four hours than he did while on the three-hour 



362 PRACTICAL INFANT FEEDING 

feeding, the change has done him no good, and he May be actu- 
ally taking less per day, though more at each individual feeding. 
The above are the ordinary causes of loss of appetite in 
babies under a year old. There are a few babies, however, in 
whom none of these causes are operative, and who never seem 
to have any desire whatever for food. They usually are seen in 
neurotic families. In this type of child the lack of desire for 
food is constitutional, and they seem to be able to get along on 
very little. There is nothing in the food that is wrong, no dis- 
ease of the baby, nothing wrong with the regime; the baby 
simply does not care about eating. Indeed, the two most 
marked cases of this sort of loss of appetite that I can recall 
occurred in families where everything connected with the routine 
of the babies could not have been improved upon in any way, 
and still they would not eat satisfactorily, taking only 3 or 4 
ounces of milk at some feedings, as much as 6 or 7 ounces rarely, 
and showing as little inclination for solid food. These babies, 
as a rule, have no sign of rickets or any sort of indigestion; they 
are happy and apparently do fairly well on their scanty diets, 
although they naturally do not weigh as much as babies of the 
same age who eat well. One of these children I have had the 
opportunity of following carefully for about three years. She 
never ate well even when a small baby, and at present eats no 
better. She is never sick, is not at all subject to colds or infec- 
tions, and is a perfectly healthy child in every way, except that 
she is very slender, and rather smaller than other children of 
her age. Loss of appetite of this sort is very trying to the family 
and to the doctor, and treatment is not very satisfactory. In 
the first place, the daily routine of the baby should receive 
careful scrutiny and, if possible, a competent nurse should be 
secured, who will have entire charge of the preparation and 
administration of the food. Four-hour feeding intervals should 
be used, and if the baby is taking only a small amount at each 
feeding, as concentrated a food as possible should be given. 
The baby should be taught to eat from a spoon, and solid food 
begun as early as possible (any time after the sixth month). 



HABITUAL LOSS OF APPETITE 363 

Small amounts of cereal, beef juice, or vegetable juice can be 
given. Olive oil is a concentrated food which is usually well 
borne, and a teaspoonful of this can be given three or four times 
a day. The baby should be out of doors as much as possible 
and be absolutely free from all excitement. There should never 
be more than one person in the room with him while he is being 
fed, and, in general, he should see as few people as possible. 
Usually it is not well to cater to a baby's tastes, but in this 
sort of case if any food is found which he likes, and will take 
well, as much of it should be used as is possible. This sort of 
loss of appetite is not to be confused with the sort about to be 
described, which is usually dependent upon poor training, and 
to generally unstable conditions in the household. 

Loss of Appetite in Children from One to Eight Years Old 
Due to Poor Daily Routine. — One of the commonest sort of 
cases that a pediatrist sees in his office is the badly brought 
up, spoiled child, who will not eat enough or the right sort of 
food. For purposes of discussion, especially as regards treat- 
ment, these may be divided into two groups, according to age: 

1. From one to four years. 

2. From four to seven or eight. 

1. A child very frequently does not hke solid food, and as 
each new article of food is begun, such as cereal, vegetables, 
or eggs, he spits it out. The mother thereupon discontinues 
that article of food, and tries something else, with the same 
result, so that finally, at the age of eighteen months or two 
years, the child is taking nothing but a large quantity of milk, 
and perhaps one or two other articles of food which he may 
happen to like, such as toasted cornflakes, graham crackers, 
or potato. He is flabby and pale, fretful and capricious, and 
runs the whole family. There should be no question of what 
a child likes or dislikes when he is beginning to take solid food; 1 
he should be made to take everything that is offered, even ^ 
if his nose has to be held, and it has to be forced down. That 
is, unless he lias an actual idiosyncrasy to some food, and is 
made sick by it, as some children are with eggs especially. 



364 PRACTICAL INFANT FEEDING 

It is not at all to be wondered at that some children do not 
at the beginning like solid foods when they are changing from 
an exclusive milk diet to a mixed one. The solid food is abso- 
lutely strange to them, it feels differently in their mouths, they 
do not know how to chew, and more of an effort is required in 
swallowing. So no article of food should ever be discontinued 
simply because the child spits it out the first few times. With 
persistence, a child can be made to like anything, and it is very 
important to begin at the beginning, and see that he is trained 
to eat each new food as it is offered. These likes and dislikes, 
acquired in babyhood, may be continued into later childhood, 
and may be the source of a good deal of trouble. I well remem- 
ber one of my own children who would not at first eat spinach; 
and it was only after several days of forcing that she grew accus- 
tomed to it, and has always after eaten it without any trouble. 

The physician usually sees a child such as I have been de- 
scribing at the age of eighteen months or two years. Treat- 
ment is almost always satisfactory if persisted in, although it 
is not easy, and we frequently have children in the private 
ward of the Children's Hospital who are sent in with a trained 
nurse for no other reason than to be taught to eat. 

Disease or indigestion of any sort is, of course, first ruled 
out by physical examination, urine and stool analysis, etc. It 
is always desirable to secure a skilled children's nurse for these 
cases if possible, as they very frequently are so used to the 
mother that they know her like a book, and realize that they 
can do about as they please with her. A firm, impersonal, 
well-trained nurse is quite a different proposition, and it is 
often surprising to see how much better the child eats after the 
mother has retired in favor of the nurse. If there has been a 
great deal of milk in the diet this should be reduced to 24 or 
32 ounces per day or even less. Overfeeding with milk is a 
common cause of lack of desire for other food, and it is not 
well to let any child have over a quart a day. The next essential 
is to put the child on absolutely regular feeding intervals, every 
four hours, and to allow nothing whatever between meals. If 



I 



HABITUAL LOSS OF APPETITE 365 

he eats nothing at one meal, he gets nothing until the next one. 
He must be made to see that the nurse's will is stronger than his 
own, and that she pays no attention to his Hkes and dislikes. 
Many times cutting down the amount of milk in the diet, regular 
feeding hours, and substitution of the nurse for the mother 
will bring the desired results, but in some cases forcing may be 
necessary. The child's nose is held and when he opens his 
mouth to cry the spoon is inserted, the tongue depressed, and he 
involimtarily swallows a part of the food at any rate. Usually 
a few day's of this sort of training teaches him that the nurse 
is not to be trifled with, and, rather than be forced, he will eat 
peaceably. There was a three-year-old boy in the hospital 
recently who was so obstinate that each time after he was fed 
he put his finger down his throat in order to induce vomiting, 
and vomited everything he had eaten. He was immediately 
fed again, and the process repeated several times. After a few 
days of this he began to reaHze that it was easier to eat than to 
be fed, and there was no more trouble. 

Drugs do no good whatever in these cases; these children 
are not sick, and it is a question of poor home training, lack of 
discipline, and individual obstinacy more than anything else. 

Poor Appetite in Children from Four to Eight Years of Age. 
— In older children loss of appetite is more frequently caused by 
eating between meals than by any other one thing. Lack of 
fresh air, overexcitement, and getting overtired are also potent 
causes. The excitable, active child, who is in a hurry to get 
off to school, in a hurry to get home, in a hurry to get out to 
play, and who often becomes overtired by trying to keep up 
with older and stronger pla3nm.ates, never eats well; he is too 
much interested in other things. The mother, seeing that he 
eats Httle at table, gives him bread and jelly between meals at 
frequent intervals, ''so that he will not starve to death," with 
the result that he is never hungry. The candy habit also plays 
an important part, fathers with "loUypops" being often at the 
hottom of it. 

The first essential in treatment is to give the child nothing 



366 PRACTICAL INFANT FEEDING 

whatever between meals. He comes to the table, sits there 
quietly until the meal is finished, and gets nothing until the 
next meal, whether he has eaten or not. Physical and mental 
rest is of the utmost importance, and in severe cases it may be 
necessary to take the child from school for a few weeks so that 
he can get the necessary rest. He should He down quietly for 
an hour after his dinner, and be in the house and quiet at 
least a half-hour before supper. If he has been going to bed at 
all hours of the night, as these children frequently do, he should 
be put to bed earlier. If he has been in the habit of pla3dng 
with children a good deal older and stronger than himself, he 
should be separated from them for a while, at any rate, and 
put with children nearer his own age, if possible. A change of 
scene is often very beneficial to these run-down, poorly eating 
children, and it may make little difference where they go, as 
long as the surroundings are different. 

Tonics are usually of some value, and the one which has 
given me best results is the following: 

I^. Tincture of nux vomica 5ij ; 

Glycerinated elixir of gentian. . . ,ad. Bvj. — M. 
S. — One teaspoonful in water before each meal (for a child five years old). 

With intelligent, tractable children suggestion is sometimes 
very valuable. At the first visit to the doctor's office a calendar 
with the days of the month on it is given, together with a number 
of little gold stars and an equal number of black ones. The 
child is told that her mother and the doctor want her to eat 
better, and that the calendar and the stars are to serve as a 
reminder to her. The calendar is hung in the dining room, 
and if she has eaten satisfactorily for a day, a gold star is stuck 
on the calendar. If she has not, a black star is used. She re- 
turns to the doctor's office in ten days bringing the calendar 
with her, and if she can show seven gold stars, she gets a prize, 
such as a game, book, or doll. The value and desirability of the 
prize and the disgrace of black stars is impressed upon her 
most emphatically at the first visit. With certain children this 
works wonders, as it arouses their interest and gives them 
something to work for. 



CHAPTER XVII 
RICKETS 

Rickets is a very common constitutional disease of some- 
what obscure and compKcated etiology, the chief manifestation 
of which is a diminished calcium deposition in the growing bone. 

Occurrence. — Rickets occurs most commonly between the 
ages of six and eighteen months, although it is not infrequently 
seen earHer. The earliest well-marked case that I have myself 
seen was in a breast-fed baby of three months. It is probable 
that the cases of so-caUed "fetal rickets" which have been 
reported have been, in reality, not rickets, but osteogenesis 
imperfecta, or chondrodystrophy, and it is questionable if an 
imdoubted case of true congenital rickets has ever been reported. 
Late rickets, that is, rickets coming on after the age of three 
or four years, may occur, but is extremely rare. The rachitic 
deformities that one so often sees in children over two or three 
years of age do not represent an active rachitic process; the 
rickets has healed, and the deformities are the remains of it. 

It is especially likely to occur in premature babies. Of 
70 prematures followed by Huenekens,^ 58 developed definite 
rickets. It is not going too far to say that almost every prema- 
ture develops rickets to a greater or lesser degree; this is borne 
out by the cHnical experience of everyone who is seeing many 
infants. 

It is also very Hkely to develop in twins. 

Rickets is an extremely common condition, especially among 
the hospital class in the large cities of the temperate zone. 
Morse,^ of Boston, in 400 consecutive dispensary babies under 
two years of age found definite evidence of rickets in 80 per cent, 

* Journal-Lancet, December 15, 1917. 

" Jour. Amer. Med. Assoc, vol. 34, March 24, 1900. 

367 



368 PRACTICAL INFANT FEEDING 

This figure corresponds closely with those of observers in other 
countries. All observers are likewise agreed that it is much 
more common in the congested districts of cities than any- 
where else, and that the poorer classes are the ones that suffer 
most from it. Mild cases are, however, not unconomon even 
among babies of the wealthy classes, who have been apparently 
properly fed and cared for. In the upper classes it is not ordi- 
narily severe, however, and it is probably not possible for any 
but the very mildest rickets to develop in a baby who was born 
at full term, and whose feeding and general hygienic care have 
been satisfactory. 

It is a disease of the Temperate Zone, and it is not at all 
frequent in very hot or very cold countries. 

In 1918 Hess,^ of New York, who has for long been a diligent 
student of rickets, pubHshed letters from several physicians 
in the tropics, portions of which are quoted. 

Dr. J. E. Ker, Jamaica, British West Indies: 

"Rickets as we know it in infants in large towns practically 
does not exist here in Jamaica. Beaded ribs and square heads 
are of the very rarest occurrence.'' 

Dr. R. Scheult, Colonial Hospital, Trinidad, Port of Spain: 

* 'During my twenty-four years of hospital practice in this 
colony I have not met a single case of rickets, although hundreds 
of children are treated in our children's ward each year." 

In the large cities of America it is more common in negro 
and ItaUan children than in any other groups, and it is rare to 
see a negro or an Italian child without well-marked evidence of 
it. Furthermore, the extreme cases of rickets almost always 
are seen in negroes or Italians. It is not at all common, however, 
in these races when living in their natural habitat. 

Dr. W. B. Pierce of Panama writes^: "I have yet to see my 
first case of rickets in the West Indian negro child. My col- 
leagues who have been here much longer tell me that West 
Indian children never have rickets." 

1 Jour. Amer. Med. Assoc, vol. 70, March 30, 1918. 

2 Quoted by Hess, loc. cit. 



RICKETS 369 

In the United States it is not nearly so common among the 
rural negroes in the South as it is in the city negroes in the 
North. 

Bottle-fed babies are much more likely to develop rickets 
than those fed on the breast, although breast-fed infants are not 
immune, especially those who are nursed too long, without 
supplementary diet. The seasonal incidence of the disease is 
rather striking; all statistics show that it is much more common 
in the winter and spring months than at any other time. 

Pathology. — Although rickets is a constitutional disease, 
in the sense that it affects several tissues of the body, the most 
important and most characteristic pathologic changes occur 
in the bones. 

In order to understand the changes which take place in 
rachitic bone it is necessary to understand the essentials of 
normal bone growth. 

A long bone consists essentially of two parts — the epiphysis 
and diaphysis, or shaft. The epiphysis is formed, in the young, 
of cartilage. The cartilage cells of the epiphysis, which are in 
juxtaposition to the end of the diaphysis, are constantly being 
converted into bone, while the epiphysis itself grows by the 
formation of new cartilage cells. ^ The zone of tissue which is 
formed between the true bone of the shaft and the cartilage 
of the epiphysis is known as ''osteoid" tissue, and is converted 
into true bone in the healthy infant by the extensive deposition 
of calcium salts. This is called the ''zone of ossification," and 
forms normally a rather sharply defined band at the junction 
of the shaft and epiphysis. By the continual presence of a 
zone of ossification and the continual conversion of the cartilage 
of the epiphysis into true bone the shaft grows in length. 

In rickets the specific bone changes are most marked at the 
junction of the epiphysis and diaphysis, i. e., the "epiphyseal 
line." 

There is a great increase in the zone of proliferating osteoid 
tissue, and a failure of calcium deposition in this tissue, with a 

1 E. H. Nichols, in Keen's Surgery, vol. 1. 
24 



370 



PRACTICAL INFANT FEEDING 



consequent absence of the zone of calcification. There is an 
ingrowth of a dense network of fine blood-vessels into the zone 
of osteoid tissue, giving rise to an enlarged, hyperemic, and soft 
epiphysis. The periosteum about the shaft of the bone is also 
changed, being considerably thickened, and depositing a large 
amount of new tissue on the cortex. This new tissue is, how- 
ever, not true bone, and consists partly of cartilage and partly 
of osteoid tissue, in which no deposition of calcium takes place. 



Epiphysis 



Center of 
ossification 



Proliferating 

cartilage 
Hypertrcphic 

cartilage 
Zone of provisional 

calcification 



Diaphysis 




Fig. 8. — A vertical section through the epiphysis and shaft of long bone of 
child at birth. Low power. (E. H. Nichols, in Keen's Surgery.) 



Such a process gives rise to a soft bone, which is easily deformed 
or fractured if it is subjected to any stress or strain. 

Normal bone contains about 60 per cent, of inorganic mate- 
rial, chiefly salts of calcium and phosphorus. A rachitic bone 
has a greatly increased water and diminished salt content, so 
that it may contain only 20 per cent, of inorganic material, 
instead of the normal 60 per cent. During the active stage of 
rickets there is a greatly decreased calcium retention by the 
body, in several cases an actual negative balance, that is, more 



RICKETS 



371 



calcium is given off in the stools and urine than is taken in with 
the food. During the stage of healing the calcium balance is 
positive, and more is likely to be retained than would be the case 
under normal conditions. 




Hyaline cartilage 



WT 



\ 






\)ivv ^^MM"^"^ 




Hypertrophic 
zone 



5one of osteoid and 
cartilaginous new 
trabeculse; line of 
provisional calcifi- 
cation wanting 



Fig. 9. — Longitudinal section through rib at junction of rib with car- 
tilage from a case of marked rickets. Low power. (E. H. Nichols, in Keen's 
Surgery.) 



One would expect that in such a condition the blood might 
show a diminution of calcium. This has been studied by 
Rowland and Marriott/ who found, however, in 11 well-marked 



1 Prac. Amer. Pediatric Soc, 1916. 



372 



PRACTICAL INFANT FEEDING 



cases of rickets that the calcium content of the blood was normal 
or nearly normal. 

Etiology. — Not enough calcium is deposited in the growing 
hone. 





#s 


.#*! 




k-%r 






^ 




^iH 


S 


fi^ 




1^1 


^H^ 




/ 


,1 




k 




1 




'- ' '-4 


h-.-M 


/•ilii-naii. 


%-j 


&-%. 


^^^ 
»'' 

G 


mmm 




^^^^H^^^ ^ v'^^^H 



Fig. 10. — Rickets: a, Normal bone with dear line of ossification; b and 
c show broad bands of osteoid tissue instead of this line; their diaphyses are 
firm, delicate, and straight; d, form of rickets in which the diaphysis is weak- 
ened, covered with periosteal new bone, and fractured. (MacCallum.) 

This is the central fact of rickets, and is perfectly clear. 
The hard thing to explain is why not enough calcium is depos- 
ited, what conditions bring about the faulty calcium metabolism, 
and despite much investigation the etiology of rickets still 
remains obscure. It is not exaggeration to say that almost every 
podiatrist of experience has offered an explanation of rickets, 



RICKETS 373 

and the literature is, therefore, flooded with many contradictory 
and widely varying theories, some of which are very far fetched 
and have little basis in fact. 

There are two main ways to get at the problem. 

1. The method of statistical inquiry and clinical observation 
applied to actual cases of rickets in infants. The type of child 
in which rickets develops, the seasonal and racial occurrence, 
the clinical results of various forms of therapy, and so on, 
represent substantial facts from which valuable conclusions may 
be drawn. 

2. The experimental method, applied largely to animals, the 
production of artificial rickets by various agencies, and a study 
of the chemistry of the condition so produced. 

Clinical Observations. — All clinical observers are agreed that 
three main facts stand out in any consideration of the etiology of 
rickets: 

(a) That babies who are poorly fed are most likely to have it. 

(h) That poor hygiene, poor air, poor living quarters, and all 
that goes with poverty has a great deal to do with it. 

(c) That full-time babies who are fed correctly and who are 
brought up under the best of hygienic conditions are very 
unlikely to have rickets, and if they do have it, it is only in the 
mildest form. 

Clinically, one sees rickets especially in babies who have 
been fed on diets containing a large amount of carbohydrate, 
with inadequate amounts of fat and protein. It is common in 
babies who have been fed on condensed milk, or on proprietary 
foods which contain large amounts of sugar and starch, and but 
little of the other food elements. Most observers are agreed 
that a fat-poor and carbohydrate-high diet predisposes to 
rickets. 

It also often occurs in babies who have suffered from chronic 
fat indigestion of the type with soapy stools, where the fat and 
protein intake is high and the carbohydrate intake low. 

It is also fairly common in breast-fed babies who have been 
kept on the breast too long; and have presumably suffered a 



374 PRACTICAL INFANT FEEDING 

salt starvation. There is a possibility, however, that some of 
these cases may not be true rickets at all, but osteoporosis. 

It has been noticed clinically for years that babies who do 
not go out of doors much and who get but little sunshine are 
very likely to develop rickets. This is so striking that some 
observers have thought that lack of fresh air was the entire 
cause of the disease. 

Chemical and Experimental. — The hypotheses that have been 
offered to explain the essential pathologic fact of rickets, i. e., 
that not enough calcium is deposited in the growing bone, are 
three in number: 

1. Lack of calcium in the diet. This theory has little to 
support it, as the blood calcium, according to the few investiga- 
tions that have been carried out, is practically normal. Further- 
more, in animals it is not possible to produce true rickets by 
calcium starvation. It is true that a condition called "osteo- 
porosis" is produced which somewhat resembles rickets, but is 
not identical with it. In this condition the bones are soft, and 
their calcium content is diminished, but the microscopic changes 
are not those of true rickets. As soon as adequate amounts of 
calcium are offered in the diet the bone quickly absorbs it, 
while in true rickets the giving of calcium does not bring about 
increased calcium deposition. 

Furthermore, in most cow's milk mixtures which are fed to 
babies who develop rickets there is a large excess of calcium over 
the amount needed. 

2. That adequate amounts of calcium may be given in the 
food, but that it is not absorbed. The argument against this 
theory is that the blood calcium is normal, and that if the 
absorption of calcium was insufficient, osteoporosis, and not true 
rickets, would result (Rowland) . 

3. That calcium is absorbed in sufficient amounts, but that 
for some at present unknown reason the growing bone is unable 
to absorb it. This theory is reached by a process of exclusion, and 
by the fact that the blood calcium is present in normal amounts. 
It is the theory held at present by most students of the disease. 



RICKETS 375 

It is quite another question upon what factors the inability 
of the growing bone to absorb calcium depends, and is at present 
unsolved. 

It is possible to produce rickets in rats and in puppies in 
a number of different ways, and at the present time much 
research work is being done on this phase of the problem, especi- 
ally by investigations in this country^ and in England. Atten- 
tion has been centered especially on a lack of the fat-soluble 
vitamin and phosphate in the diet. 

Mellanby^ in 1919, as a result of extensive investigation on 
puppies, reached the conclusion that lack of the fat-soluble 
vitamin in the diet had, at any rate, a great deal to do with the 
development of rickets, and brought forward a good many 
apparently valid arguments to sustain his conclusions. He 
found that cod-liver oil, butter, and suet, all of which contain 
considerable amounts of ''fat-soluble A," had a weU-marked 
protective action against the development of the disease in 
pups. Vegetable juices were also found to have some inhibitory 
effect. 

He also showed that an abundance of calcium would not 
protect when the diet was deficient in the ''antirachitic factor." 
He believed that if milk is to contain the antirachitic factor, 
the diet of the individual from whom the milk comes must con- 
tain an adequate amount of it, such as grass for cows, or green 
vegetables and butter fat for nursing women. He believed 
that lack of these substances in the diet of nursing mothers 
might explain why rickets occurs sometimes in. breast-fed 
babies and why it is more common in bottle-fed babies in the 
winter months, when the cow's diet is likely to contain little 
fresh, \itamin-containing food. 

"An adequate diet is itself a unit, and its soundness, to a 
large extent, consists in the mutual assistance and interplay 
in the metabolic changes the elements experience in the body. 
The absence of or deficiency in one element means the ineffec- 
tiveness of another. It is possible to imagine an abundance 

1 Lancet, March 15, 1919. 



376 PRACTICAL INFANT FEEDING 

of accessory food factors in the diet which may, however, be 
ineffective because of some wrong balance in the energy-bearing 
materials" (Mellanby). 

This would indicate that the writer believed the fat-soluble 
vitamin to have a regulatory effect upon calcium metabolism. 

After Mellanby 's work in 1919, the Vitamin Committee 
of the British Research Council decided that rickets was defi- 
nitely a deficiency disease, probably due to lack of ''fat-soluble 
A" in the diet, and stated this in their extensive report.^ This 
was apparently a somewhat premature conclusion, as Mellanby's 
views have by no means been accepted by other students of 
rickets, notably Paton and his collaborators in England, and 
McCoUum, Hess, Park, Howland, and their associates in this 
country. Paton, Findlay, and Watson- found that pups kept 
in the country under the best hygienic conditions and fed on a 
diet containing practically no ''fat-soluble A," but allowed 
plenty of exercise and fresh air, developed no rickets what- 
ever, but that if pups from the same litter were kept in the 
laboratory under ordinary laboratory conditions with lack of 
fresh air, sunshine, and exercise, and fed on a diet containing 
an abundance of "fat-soluble A" in the form of butter fat, they 
almost uniformly developed rickets. They conclude that under 
ordinary laboratory conditions a liberal allowance of "fat- 
soluble A" neither prevents the disease nor cures it after it has 
developed, and they do not agree that it is essentially a deficiency 
disease. 

McCollum^ and his collaborators found that rickets might 
develop in experimental animals on diets in which the faults 
lay in somewhat different factors, and that a low content of 
"fat-soluble A," a low calcium, poor quality of protein, and 
unsatisfactory salt combinations might all contribute to the 
etiology of the disease. 

"Any suggestions regarding the absence of a specific anti- 
rachitic substance or deficiency of "fat-soluble A" or calcium 

1 Med. Research Commission, spec, reprint series No. 38, London, 1919. 

2 Brit. Med. Jour., April 23, 1921. ' Jour. Biochem., vol. 41, 1920. 



RICKETS 377 

as the primary agent in the production of rickets would be ill 
considered, and might be far from the truth. A specific lack 
of ' 'fat-soluble A" cannot be regarded as the sole and only 
possible cause of the disease. At present it is only possible 
to say that the etiologic factor is to be found in an improper 
dietetic regime" (McCollum et al.). 

Hess and linger/ in a study of the effect of diets poor and 
rich in "fat-soluble A" upon the development of rickets in infants, 
showed that the lack of this factor did not cause an increased 
frequency of occurrence, and in several papers have stated that 
they do not believe it is the cause of rickets. 

"Our experience leads us to believe that except under excep- 
tional circumstances, as in time of war, the danger to the infant 
and to the child from a deficiency of the fat-soluble factor is 
one not to cause great apprehension. There is a growing danger 
of attributing every unexplained growth impulse to the new, 
attractive, but ill-defiQed vitamins — of their sharing with the 
secretions of the endocrin glands the fate of becoming the dump- 
ing ground for every unidentified factor" (Hess and Unger). 

There is recent evidence to show that lack of phosphorus 
in the diet, or improper assimilation of it, may have a good 
deal to do with rickets. 

Park^ and his associates found that in rats a diet low in 
phosphorus and "fat-soluble A" produced a condition closely 
resembling rickets. When the deficiency in phosphorus was 
made up, the deficiency in "fat-soluble A" still existing, no 
rickets developed. They believe that: 

1. The phosphate ion may be a determining influence for 
or against the development of rickets. 

2. The level of the blood phosphorus is, in all probability, 
determined in part by the amount of the "fat-soluble A" avail- 
able for the needs of the organism. 

Sherman and Pappenheimer^ were able, by the use of a 

^ Jour. Amer. Med. Assoc, January 24, 1920, vol. 74. 

2 Bull. Johns Hopkins Hospital, May, 1921. 

3 Proc. Soc. Exper. Biol, of Med., 18, 193, March, 1921. 



37^ PRACTICAL INFANT FEEDING 

simple diet lacking phosphorus, to produce rickets in rats in 
every case. Complete protection was afforded by the addition 
of 0.40 per cent, potassium phosphate to the diet. 

Another point in favor of lack of phosphorus being con- 
cerned with the etiology of rickets is furnished by the work of 
Rowland and Kramer,^ who found that after the administration 
of cod-liver oil to cases of rickets the blood phosphorus was 
greatly increased, and that in active cases of rickets the blood 
phosphorus was always decidedly lower than normal. 

// must be concluded from the experimental and clinical investi- 
gations upon the etiology of rickets that it is a metabolic disease 
concerned in some way with faulty calcium metabolism, and caused 
by improper feeding and hygienic conditions. It is fair to say 
that calcium, phosphorus, and the fat-soluble vitamin probably have 
certain interrelationships, the normality of which must be main- 
tained in the metabolism if rickets is not to develop. Further than 
this we cannot go at present without unwarranted theorizing. 

As a summary it may be well to set down in numeric order 
ten established facts which we do know concerning the etiology 
in human infants and which will some day fit together into a 
well-connected whole when the exact cause is discovered. 

1. The essential pathologic perversion is a lack of calcium 
deposition in the growing bone. 

2. It is not caused by a lack of calcium in the food. 

3. The blood calcium is essentially normal in quantity, the 
blood phosphorus diminished. 

4. It occurs especially in infants who have been fed on 
diets high in carbohydrate and poor in fat, protein, and salts. 

5. It also occurs frequently in infants fed on diets high in 
fat, especially when fat indigestion is present, of the type with 
constipated light colored stools, containing a large amount of 
calcium soap. 

6. It occurs in about three-quarters of all premature babies, 
provided they are a month or more premature. It also occurs 
frequently in twins. 

1 Proc. Amer. Ped. Soc, 1920. 



RICKETS 379 

7. Poor hygienic surroundings, lack of sunlight, and fresh 
air undoubtedly have something to do with its causation. 

8. It occurs much more frequently in the winter and spring 
than at any other time. 

9. It occurs more frequently in negroes (and Italians) than 
in any other races when they are living in the large cities of this 
country. When they are living in their native habitat it is not 
common. It has been found that negroes with rachitic children 
in New York eat very Uttle fresh fruit, fresh vegetables, and 
milk products, and rickets flourishes. In their native habitat 
they eat large amounts of green vegetables and fruits, and have 
practically no rickets.^ 

10. Cod-liver oil possesses marked antirachitic powers, both 
as a prophylactic and as a cure. It is rich in "fat-soluble A." 

Symptoms. — The onset is gradual, and the early symptoms 
may extend over a considerable period of time before well- 
marked rachitic lesions of the bone are seen. Sweating about 
the head and restlessness at night are always given as two of 
the most important symptoms of early rickets, and while it is 
true that rachitic babies do sweat about the head, it is also 
true that many normal babies do likewise, and it is not uncom- 
mon to see a baby's pillow drenched with sweat when he is 
perfectly healthy and has not then or at any other time a sign 
of rickets. Adults vary greatly in their tendency to perspiration. 
So do infants, and, therefore, sweating about the head by itself 
cannot be taken as a very important diagnositc sign of rickets. 
Restlessness at night is likewise often due to other causes, but 
when these two symptoms occur together, especially if there is 
also a loss of appetite, and a flabby condition of the flesh, a 
condition of early rickets is probable. Poor color, a flabby con- 
dition of the flesh, and loss of appetite, especially the two former, 
are signs from which practically no rachitic infant is free, and 
are often the earliest signs noted. In the periodic inspection of 
one's feeding cases early rickets must always be watched for, 
and the pasty color with rather bluish discoloration under the 
1 Hess and Unger, Jour. Amer. Med. Assoc, vol. 70, March, 1918. 



380 PRACTICAL INFANT FEEDING 

eyes and over the bridge of the nose, together with poor tissue 
turgor, often indicates beginning rickets, and the desirabiHty of 
prophylactic cod-Hver oil therapy. 

Not a few apparently well-cared-for infants in private prac- 
tice will show these four early signs, combined perhaps with a 




Fig. 11. — Rickets, characteristic "square head" and enlarged wrist epiphyses. 

slight rosary, delayed dentition, and a fontanel somewhat larger 
than normal. In most cases with proper treatment the condi- 
tion goes no further. 

Rachitic infants vary greatly as regards their apparent 



RICKETS 381 

general nutritional condition; many are fat and of good weight, 
others are emaciated and obviously in poor condition. All have 
poor tissue turgor, whether fat or thin. 

In well-developed rickets the following are some of the more 
important changes seen. They may exist all together in severe 
cases or more frequently only three or four rachitic manifesta- 
tions will be well marked. 




Fig. 12. — Roentgenogram of skull, showing frontal thickening. 

The head is large in relation to the chest, and often shows the 
characteristic frontal bosses, which consist of a thickening of 
the bone on both sides of the head in the frontal region. This 
characteristic shape of the head may persist for years. 



382 PRACTICAL INFANT FEEDING 

The bone of the skull is often considerably thickened, which 
is well shown in Fig. 12. 

In the acute stages of the disease, especially in young babies, 
the bones of the skull are often very soft, and the head may be 
flattened on the back or on the side upon which the baby is 
accustomed to rest. In some cases the back of the head is very 
flat and the forehead protuberant, giving rise to a brachy- 
cephalic type of skull. 

Cranio tabes is not uncommon. This consists of areas of 
softening in the skull bones, most common in the parietal region. 
They vary from the size of a dime to that of a quarter. When 
pressed by finger these areas may give a crackHng sensation like 
heavy parchment, or may feel soft and doughy. Cranio tabes is 
most commonly seen at the third or fourth month, when perhaps 
there are few other signs of rickets, but it may always be con- 
sidered (excluding syphilis) as a sign of severe rickets. It is 
likely to disappear at the eighth or ninth month, when the other 
signs, such as enlarged epiphyses and rosary, begin to be more 
prominent. The sutures of the skull may be widely open, and 
the fontanel almost always is larger than it should be for the 
age of the child, and closes late. The anterior fontanel should 
close normally at the eighteenth month, and in many well- 
developed infants will be closed considerably before this. In 
rickets it may be widely open as late as two years or after. 
According to Still, if it is greater than 1 inch in each diameter 
at one year of age it is abnormal, and indicates a probable 
rachitic process. This is probably true even if there are few 
other signs of rickets, and the rate at which the fontanel closes 
is one very good index of a baby's general development. 

The Teeth and Jaws. — The teeth are late in erupting, but 
individual babies vary so much in the time at which the first 
teeth appear that delayed dentition alone cannot be taken as 
an indication of rickets. I saw not long ago a perfectly normal 
child of thirteen months who did not have a tooth in her head, 
and yet had no signs whatever of rickets. She did not cut 
her first tooth until fourteen months. This is, of course, abnormal 



RICKETS 383 

dentition, and yet the child herself was perfectly healthy. 
Many babies will begin to cut teeth at six months, but denti- 
tion need not be considered abnormal unless the appearance 
of the first teeth is delayed until the eighth month. According 
to Morse^ a normal infant should have 1 tooth at eight months, 
2 at nine months, 6 at twelve months, 12 at eighteen months, 
and 16 at two years. These figures are all somewhat later 
than the average^ Defective calcification of the enamel is 
marked, but is most likely to be seen in the permanent denti- 
tion, as calcification of the deciduous teeth begins in the fifth 
or sixth month of intra-uterine life, and would naturally not be 
affected so much as that of the permanent teeth, which should 
be taking place while the rachitic process is going on. 

In the typical rachitic form of hypoplasia met with in the 
permanent teeth the ones most affected are the central and 
lateral incisors, the tips of the canines, and the crowns of the 
first molars (Dick). ^ 

The deciduous teeth are lost early, with a resulting mal- 
occlusion in the second dentition, and it is probable that rickets 
is one of the most potent causes of this malformation. The 
upper jaw is narrowed or V shaped in form; the palatal arch 
is vaulted and narrow, and the teeth, therefore, crowded. 

The Long Bones. — It is in the long bones of the body that the 
most striking manifestations of rickets appear. The clavicles 
very frequently show an angular bending outward, often due 
to green-stick fractures, or again the bone may be much shortened 
on account of old fractures, and calluses may be felt. 

The rihs, in common with the rest of the bones, are soft, 
and this may give rise to marked deformity of the chest. The 
rachitic chest is usually narrow at the top, and flares out broadly 
at the base. There is often a depression at the junction of 
each rib and costal cartilage especially marked from the fourth 
to the eighth ribs, giving rise to the so-called ''Harrison's 
groove." At the junction of the rib and cartilage there is an 

1 Jour. Amer. Med. Assoc, 1900, vol. 34, March, 1824. 

2 Brit. Jour. Dis. Chil., vol. 13, November, 1916. 



384 



PRACTICAL INFANT FEEDING 



overgrowth of osteoid tissue (see Pathology), forming small 
bead-Hke excrescences which can be seen and felt on the out- 
side of the chest wall. This is the so-called "rosary," and is 




Fig. 13. — Narrow flaring chest, 
also characteristic pot-belly and ex- 
treme pronation of the feet. 



Fig. 14. — The rosary. 



one of the most common signs of rickets, and it is probable 
that no rachitic child is without one. It has been said that 
a "rosary" is a pathognomonic sign of rickets. Beading of the 
ribs or "rosary," according to Hess and linger,^ also may occur 
1 Jour. Amer. Med. Assoc, vol. xix, May 20, 1920. 



RICKETS 



385 



in scurvy when uncomplicated by rickets, so it is probably not 
correct to regard it as a pathognomonic sign. A good many 
apparently normal babies will show slight beading of the ribs, 
and it is often difficult to know what should be called a rosary 
and what not. There is no very definite standard to go by, 

r 




Figs. 15, 16. — Contrast between knock-knee and bow-legs. 

but personally I should call any beading that was plainly visible 
to the eye a rachitic rosary, and would pass any beading not 
visible to the eye as normal unless each bead were about as large 
as one's little finger-naiL The state of nutrition of the child 
has, of course, a good deal to do with the visibility of the beading. 
The extremities show striking changes. There may be ex- 
25 



386 PRACTICAL INFANT FEEDING 

treme bowing of the bones of the arm and the leg, with multiple 
fractures. The most common deformity is lateral bowing of 
the tibiae; the femur and bones of the arm are not so likely to 
be affected. The deformity of the legs may vary all the way 
from sHght bowing to the most extreme changes (Figs. 15, 16). 
Knock-knee may also occur, and may sometimes be so 
severe as to seriously interfere with locomotion. The legs 



^^^Kfe.^a^^^^^^^^^^^^^^^^^^^^l 


HB 




v'lfl 


Wjk iY^ ,Y "^ 


f / Ji 


i V i^ 


u^J 




^^^^^^ .i^^^^^^^^H 


m ^IM 


r^^ 



Fig. 17. — Various degrees of deformity due to knock-knees. Note marked 
fiat-foot in all cases. 

of many rachitic babies before they begin to walk may show 
no bowing or knock-knee, but may be very small and tapering, 
so weak and flabby that walking is long delayed, and the physi- 
cian who is not familiar with rickets may mistake the condition 
for a paralysis of some sort. There is a great laxity of the liga- 
ments, which is likely to cause pronation of the feet, in many 
cases so extreme that the baby cannot walk until it is corrected. 



RICKETS 387 

The epiphyses at the knees and ankles are enlarged, and 
may be somewhat tender in the florid stage, but the most strik- 
ing epiphyseal changes take place at the wrist. These epiphyses 
may be very much enlarged, and such enlargement is always 
an indication of a considerable degree of rickets. In the milder 
cases they may be enlarged so slightly as to be scarcely notice- 
able, but the Roentgen ray will show the characteristic rachitic 
changes. 

The Spine. — Kyphosis is common. The curve is usually 
a rather long, gradual one, occurring most commonly in the 
lower thoracic and lumbar segments. The curve seen in tuber- 
culosis of the spine is shorter and more angular, and it is not 
ordinarily difiicult to differentiate the two conditions. The 
rachitic kyphosis is flexible, and when the baby is put upon its 
abdomen and the spine flexed by raising the legs the curve has 
a tendency to straighten out and does not show the degree of 
inflexibility and spasm that would be likely with a tubercular 
spine. Lateral curvature is likewise not uncommon. 

The Roentgen-ray Appearance of the Bones. — The Roentgen 
ray is often of value in the diagnosis of rickets, and is always 
valuable in determining the stage in which the rachitic process 
is, whether it is progressive, in the so-cafled ''florid" stage, 
or whether it is heahng. According to Lovett^ by Roentgen-ray 
examination three fairly distinct changes may be recognized 
in the course of the rachitic process: 

1. Swelling and rarefaction. 

2. Deformity and organization. 

3. Healing and reparation. 

First Stage. — In the milder types the ends of the diaphysis 
become frayed instead of clear cut, and the epiphysis casts 
little or no shadow. The center of ossification is small or 
absent. In the severe type the epiphyseal changes are similar, 
but more marked. In the shaft there is general bone atrophy 
and often multiple fractures. 

Second Stage. — The shadow of the epiphysis is more marked, 

1 Jour. Amer. Med. Assoc, December 11, 1915. 



388 



PRACTICAL INFANT FEEDING 



but ragged and irregular. The ends of the diaphysis begin to 
broaden. At the end of the diaphysis next to the epiphyseal 
line there often appears in the late second or early third stage a 
clean transverse white line, showing an increased deposit of 
lime in the shaft. This is apparently not to be distinguished 
from the white line of scurvy. 

Third Stage.— The epiphysis begins to assume its normal 
contour and shadow density. This represents the period of 
convalescence, and from this point on the deposition of bone 
continues. 








Fig. 18. — Schematic representation of various changes in the bone during the 
different stages. (Courtesy of Dr. R. W. Lovett.) 



As a summary of the general changes as seen in rickets 
Lovett says, ''The epiphyses show scanty and irregular osseous 
deposits and never have a clear-cut outline during the acute 
process. The end of the shaft is streaked and presents an 
irregular line at the joint end and above it a curious transverse 
zone of different structure from the rest of the bone. The 
interior of the shaft becomes chambered and irregular, and the 
whole shaft casts less shadow than normal. The ends of the 
shaft broaden at the junction with the epiphysis and put out 



RICKETS 389 

ledges on the side where strain is to be met. A compensatory 
cortical thickening occurs on the concave side of curved long 
bones." 

Systemic Changes. — In rachitic children with extreme de- 
formity of the chest respiration may be much interfered with, 
even to such an extent that life may be threatened, as Park and 




^^^ ^«SP^* ^»!Ps" ^^^^ 




/> 




Fig. 19. — Figures 19 to 22 inclusive are all from cases of rickets in the 
florid stage. Note especially the frayed-out appearance of the ends of the 
diaphyses and the indistinctness of the epiphyses. 



Rowland^ have recently pointed out. There may be a pro- 
gressive reduction in the size of the thorax, and loss of power to 
expand, followed by atelectasis of portions of the lungs, con- 
sequent impediment to the pulmonary circulation, and hyper- 
trophy of the right side of the heart. With very severe de- 
formity the power of the respiratory apparatus may be barely 

1 Bull. Johns Hopkins Hosp., 32, 101, April, 1921. 



39° PRACTICAL INFANT FEEDING 

sufficient for the needs of the body, and if any pulmonary infec- 
tion is added it fails and death results. 

A low-grade, patchy type of bronchopneumonia is responsible 
for many deaths in rachitic infants, and this is indeed the chief 
danger to life that rickets offers. 




Fig. 20. — Knee: Florid stage. 

Most rachitic children are anemic, occasionally to a severe 
degree, the anemia being of the ordinary ^'secondary" type with 
low hemoglobin and moderate diminution in the numbers of the 
red cells. This anemia is often associated with enlargement of 
the spleen, and probably a good many cases of "Banti's disease'^ 



RICKETS 



391 



and "pseudoleukemia" that have been reported in infants have 
had rickets as their basis. The spleen is frequently slightly 
enlarged in moderately severe cases without much anemia^ and 
should always be carefully felt for if rickets is suspected, as it 
is a diagnostic point of some importance. It is often difficult to 




Fig. 21. — Knee: Florid stage. 



feel a slightly enlarged spleen in a baby. The mistake that 
many people make is to press in too deeply, and to feel with 
too large an area of the fingers instead of with the tips alone. 
There is likely to be a slight enlargement of the lymph-nodes. 



392 



PRACTICAL INFANT FEEDING 



This is, however, not especially characteristic of rickets, and 
may occur in any poorly nourished infant. 

The liver is enlarged in some cases, particularly if the diet 
has been very high in carbohydrate. 

The nervous system in rickets shows an increased irritability. 
It may take the form of spasmophilia, which is so often asso- 
ciated with rickets, or it may manifest itself simply by restless- 
ness on the part of the child, especially at night, and by a 




Fig. 22. — Ankle: Florid stage. 

tendency to jump at noises or any unexpected sudden motion 
on the part of the nurse or the mother. The disposition is 
likely to be peevish and fretful, and in a hospital ward a 
child with severe rickets is usually the ''bad boy" of the 
ward. 

The tone of the muscles is poor, and in some cases the leg 
muscles may be so weak as to suggest paralysis. The abdominal 
muscles are also thin and weak, giving rise to the ''pot belly" 



RICKETS 393 

and soft relaxed abdominal walls which are so characteristic of 
this disease. 

The hair is sparse, and owing to the nervousness of the 
child and his tendency to roll his head about, it may wear off 
in spots, giving rise to a patchy, moth-eaten appearance. 




Fig. 2d>. — Stage of healing. Note especially the clearer outline of the 
epiphyses, also the broadening of the ends of the diaphyses. The white line 
is also visible, but not so marked as it is in some cases. 

Diagnosis. — ^A well-marked case of rickets can scarcely be 
confused with anything else. 

It is sometimes difficult to decide, however, in the early 
stages how much evidence is necessary before it is allowable to 
make the diagnosis. Head sweating, restlessness at night, 
enlarged fontanel, slow dentition, poor tissue turgor, and slight 



394 PEACTICAL INFANT FEEDING 

rosary constitute enough evidence upon which to base a diag- 
nosis of early rickets. Later on the enlarged epiphyses, shape 
of the head and chest, bowing of the legs, etc., make an unmis- 
takable picture. 




Fig. 24, — Stage of healing. Note especially the thickness of the tibia and the 
white line at the lower diaphyseal end. 

Chondrodystrophy Jcetalis is a condition which has sometimes 
been mistaken for rickets. This begins in fetal life and con- 
sists of a disturbance of ossification resulting in a premature 
ossification of the cartilage, with a consequent short bone. 
The arms and legs are very short in relation to the trunk, there 



RICKETS 395 

is no rosary, and the epiphyses are not enlarged. The x-ray 
shows a normal appearing epiphysis, ''which maintains its clear- 
ness and regularity of outline throughout the affection" (Lovett). 
The diaphyseal ends of the long bones also are sharp and clean 
cut in outline, and never show the frayed appearance so char- 
acteristic of rickets. 

In Jragilitas ossium there are multiple fractures, but this is 
its only real resemblance to rickets. The long bones are very 
slender, and show an extreme fragility, so that they fracture on 
the very slightest provocation. The epiphyses show none of 
the characteristic changes seen in rickets. 

Osteogenesis imperfecta is usually seen in stillborn babies. 
The bones are very thin and extremely soft, more so than in 
rickets, and bend easily in all directions. The bones of the 
skull are especially very soft and thin, so that the cranium may 
be almost entirely membranous. The condition is incompatible 
with life, and infants with it usually die soon after birth. 

Scurvy probably bears no etiologic relationship to rickets, 
but the two often coexist. In rickets there may be some pain 
in the legs, especially about the knee, but it is never as severe 
as the pain in scur\y, and most of the cases which have been 
called "acute rickets" are, in reality, probably scur\y. In 
scurvy the trouble is along the shaft of the bone, in rickets 
mostly in the epiphysis. In scurvy the x-ray shows the clear 
outline of the epiphysis, in rickets it does not. The ''white 
line" is present in both. "On the appearance of the epiphysis 
alone it is possible to differentiate the two diseases" (Lovett). 

Prophylaxis. — The prophylaxis of rickets is important, and 
it is theoretically possible by proper prophylaxis to do away 
with the disease. Sunshine, fresh air, and proper feeding are 
the cornerstones of prophylaxis, and it is probably true that few 
babies will develop rickets if they are properly fed and get a 
sufficient amount of outdoor air. Under proper feeding comes 
weaning at the right time, which should be done in most cases 
not later than the eighth or ninth month; babies fed at the 
breast longer than this will certainly in many instances develop 



396 PRACTICAL INFANT FEEDING 

rickets. Whether or not green vegetables are of any value as a 
prophylactic is an undecided question. The fact remains, how- 
ever, that babies fed upon suitable milk modifications — cereals, 
soups, and beef juice — up to the fourteenth or fifteenth month, 
and cared for adequately as to their general hygiene, do not 
develop it, so it would seem that green vegetables are not neces- 
sary as a prophylactic, provided the diet is suitable in other 
respects. Cod-liver oil is of unquestioned prophylactic value, 
and it has its particular field of usefulness in premature babies, 
who are so likely to develop rickets. It is a good idea with all 
prematures, at the third or fourth month, to begin feeding 
cod-liver oil in doses of 10 to 20 drops three times a day, which 
may be increased at the eighth month to J teaspoonful or even 
a whole teaspoonful at a dose. 

Rickets is such a wide-spread disease that it must be borne 
in mind that any feeding case or apparently normal baby in 
one's practice may develop it. Prophylaxis and a careful exami- 
nation for early rickets each time the baby is seen are, therefore, 
important. 

Treatment. — The treatment of rickets is satisfactory and 
good results may be obtained. 

Feeding. — If there is any special type of indigestion present, 
this must be corrected. The most common type likely to be 
found is a chronic fat indigestion with constipated stools con- 
taining a large amount of soap; the stools should, therefore, be 
examined. If the baby has been on a diet high in carbohydrate 
and low in protein and fat, the carbohydrate should be reduced 
and the fat and especially the protein raised to the limit of toler- 
ance. A mixed diet should be begun as early as possible; rachitic 
babies almost always do better on this sort of diet than on 
milk alone. Orange juice may be used any time, small amounts 
of strained oatmeal and meat soups may be begun at the seventh 
month, while spinach or carrot puree and beef juice may be 
started at the eighth or ninth month. Egg yolk is also of value, 
and may be given at the end of the first year. It is best given 
by hard boiling the egg, separating the yolk from the white, 



RICKETS 397 

grating it, and mixing it with the vegetables or cereal. The 
rachitic child will, therefore, be taking a much more varied diet 
than would a normal child of the same age. It is hard to explain 
scientifically, in view of what we know concerning the etiology 
of rickets, why green vegetables should be of value in the treat- 
ment, inasmuch as it is not generally believed that lack of the 
fat-soluble vitamin, which is contained in considerable amounts 
in green vegetables (especially spinach) is the cause of the 
disease. Also, inasmuch as it is not caused by lack of calcium 
in the diet, the moderate amounts of calcium contained in 
vegetables would not be especially indicated. The fact remains, 
however, that green vegetables in the diet do seem to do good 
in the treatment, whatever the exact explanation may be. 

Drugs. — Cod-liver oil and phosphorus have for long been 
used in the treatment of rickets. This combination was first 
extensively used by Kassowitz about 1880, and had consider- 
able popularity for a while, after which it rather fell into mild 
disfavor for a period, but in the last few years has had a great 
revival of popularity. At present practically all students of 
rickets are agreed that cod-hver oil alone, or combined with 
phosphorus, is of great value, and it has been shown by several 
investigators that cod-liver oil when ingested increases the 
retention of calcium and of phosphorus by the growing bone. 
It is probably even more efficient when combined with phos- 
phorus than when used alone. Prolonged administration is 
necessary if the best results are to be obtained, but Howland 
and Park^ were able to show by means of the x-vd^y that there 
was definite calcium deposition in the ''osteoid" tissue as soon 
as three weeks after beginning treatment with cod-liver oil. 
The reason why administration of cod-liver oil should increase 
the deposition of calcium in the growing bone is not known. 
It is rich in the fat-soluble vitamin, and contains a not incon- 
siderable quantity of iodin; aside from this there is probably 
nothing different about it chemically from any other fat. The 
usual dose of cod-liver oil to begin with for a baby of six months 
1 Arch. Ped.. 37. 1920. 



398 PRACTICAL INFANT FEEDING 

or under is about 20 drops three times a day. After the ninth 
or tenth month a teaspoonful at a dose may be taken. Babies 
usually take it readily, and it is less likely to upset the stomach 
or to cause loss of appetite if it is given immediately after the 
feeding than at any other time. If the stools begin to smell 
like cod-liver oil this is a sign that it is not being well assimilated, 
and is an indication for a reduction in the dose. 

If it is desired to use phosphorus in conjunction with the 
cod-liver oil, the best prescription is the following: 

R. Phosphorated oil 3ss; 

Cod-liver oil giv. — M. 

Shake well before using. 

S. — One teaspoonful three times a day. 

Each minim of the official phosphorated oil of the Phar- 
macopeia contains about rio grain of phosphorus, therefore 
each teaspoonful dose of the above prescription would contain 
about that amount. Phosphorated oil is heavier than cod-liver 
oil and has a tendency to settle to the bottom of the bottle, 
therefore it must be shaken vigorously before using, as, if it is 
not, the last dose in the bottom of the bottle might contain 
enough phosphorus to poison the child. 

Calcium. — There is probably no advantage in giving calcium 
salts to a baby with rickets, inasmuch as the food contains a 
great sufficiency, and it is probable that increasing the amount 
of calcium in the diet has no effect on the retention of cal- 
cium. 

Tincture of Nux Vomica. — Small doses of tincture of nux 
vomica may be of value for rachitic children over a year old, 
particularly if they are constipated. A child of this age would 
take from 1 to IJ minims three times a day. It is best given 
in orange juice. 

Iron. — Inasmuch as almost all rachitic children are some- 
what anemic, some markedly so, iron is usually indicated, and 
seems to do good. The best iron preparation for babies is the 
saccharated oxid, and is prescribed in powder form, a pinch or 



RICKETS. 399 

two to be given three times a day in orange juice, or mixed with 
the food. 

I^. Saccharated oxid of iron (powdered), gij. 
S. — One pinch three times a day. 

General Treatment. — Sunshine and fresh air are of the 
utmost importance. The rachitic baby should be out of doors 
as much as possible on the sunny side of the house. In summer 
there is no place like a beach for a rachitic child, and a month or 
two at the seashore sometimes works wonders. If the child is 
old enough he may be put on the beach in his pen, and may 
spend most of the day there. Several competent observers 
have thought that lack of light had a good deal to do with the 
development of rickets, and it certainly seems as though this 
might be true in some cases. On a broad beach of light colored 
sand the Hght is intense on sunny days, and it is, therefore, an 
ideal place to secure any possible therapeutic effect that light 
may have.^ Salt-water baths are also of value, and if a rachitic 
baby is at the seashore they should certainly be used. 

The rachitic baby should not be urged to sit up or to walk, 
but should be left to his own devices in this respect. He should 
be rather held back than pushed ahead, as if he walks much 
while the rachitic process is still active, particularly if he is a 
heavy baby, any bowing of the legs will become much intensified. 

Prevention of Deformity. — The treatment of the deformities 
resulting from rickets is an orthopedic problem, and there 
should be a close co-operation between the pediatrician and the 
orthopedist in this respect. It is well not to wait too long before 
calling in the orthopedist, as by the use of suitable apparatus 
he can usually prevent severe deformity from taking place. 
The three deformities that are most amenable to treatment in 
the florid stage of rickets and which come under the observa- 
tion of the medical man are bow-legs, pronated feet, and 
kyphosis. If the bowing of the legs is at all extensive it is well 

^ Since this was written several papers have appeared, showing definitely 
that exposure to sunlight increases markedly calcium deposition in rachitic 
bone. 



400 PRACTICAL INFANT FEEDING 

to have proper braces applied, and in conjunction with diet, 
cod-liver oil, and hygiene, it is often remarkable to see what 
good results may be obtained in a few months. Bowing of the 
legs may occur even before the baby starts to walk, and in these 
cases the bowing is, of course, greatly intensified as soon as 
walking begins. It is therefore wise to have the braces applied 
early, even if the baby is not walking. Braces are also often 
necessary for weak legs without any bowing. 

Extreme pronation of the feet is very common and is due 
to the laxity of the ankle ligaments. This alone may prevent 
walking, but responds very readily to treatment, and it is 
remarkable to see sometimes how well a rachitic child of eighteen 
or twenty months will walk if he has proper shoes and proper 
ankle braces, when he could perhaps barely stand before their 
appHcation. The type of shoe for rachitic children just begin- 
ning to walk is of importance. It should be a high laced shoe of 
fairly heavy leather, with a stiff sole, and often needs a steel 
ankle shank and a modified Thomas heel in order to throw the 
balance of the foot outward. A word of warning as to mocca- 
sins, which are so popular for young babies of a year or two old. 
They give practically no support to the foot, and should not be 
used for either normal or rachitic babies. Mild degrees of 
kyphosis may be treated by having the baby He on a hard flat 
surface and by not allowing him to sit up. More severe cases 
may need to be kept strapped continually to a Bradford frame. 

Course and Prognosis. — Rickets tends to heal spontaneously, 
and after a few months of diminished calcium deposition in- 
creased amounts are retained and the bone becomes hard again. 
It is not common to see active rickets after the age of two years. 
The course of the disease without treatment may last anywhere 
from four to fifteen months. With proper treatment it may be 
considerably shortened. The end-results with good treatment 
are usually satisfactory, but depend to a very large degree upon 
how soon the case is seen. It should be possible in any early 
case to prevent deformity from occurring. It is remarkable to 
see how few signs of rickets are left in most cases as the child 



RICKETS 401 

grows up if excessive deformities were not present. The legs 
slowly straighten, the epiphyses come back to normal size, the 
rosary disappears, and the head assumes a normal shape, so 
that in a great many cases by the time the child is ^ve or six 
years old one would not know that he had had rickets. The 
second dentition, however, is likely to be poor, and there is no 
doubt that a good many of the carious teeth occurring in child- 
hood have an earlier rickets as their basis. 

In some cases the deformity of the legs is so great, either 
extreme bow-legs or knock-knee, that operation has to be 
resorted to. 

The disease is not ordinarily dangerous to life except indi- 
rectly. Rachitic children are prone to infection and bear it 
poorly. Pulmonary infection of any sort is an especially com- 
mon cause of death. 
26 



CHAPTER XVIII 
SPASMOPHILIA 

Spasmophilia is a not uncommon chronic disorder of metab- 
oKsm seen usually in infants, and manifested by an increased 
irritability of the central nervous system, which shows itself by 
spasm of the larynx (laryngismus stridulus), carpopedal spasm 
(tetany), or by general convulsions. It is often latent, in which 
case it is manifested merely by increased electric and mechanical 
irritabihty. It is probably dependent upon faulty calcium 
metabolism. 

Occurrence. — ^The youngest case reported is by Wolff, in an 
infant of seven weeks.^ It is, however, rare before the age of 
three or four months, and occurs most commonly between the 
fifth and eighteenth months. It may be seen in older children 
or even in adults after parathyroid extirpation or in certain 
gastric conditions. 

It is not at all uncommon, and according to various observers 
occurs in from 1 to 2 per cent, of all infants under two years of 
age. It is not unlikely, however, that it is much more common 
than this, as many cases are latent, without active manifesta- 
tions, and pass unrecognized. It is undoubtedly true that a 
large proportion of the convulsions seen in infancy, and formerly 
thought to be due to many varied etiologic factors, actually 
rest upon a spasmophilic basis. Almost all cases are seen in 
bottle-fed babies, but it can occur in the breast fed. It is almost 
always associated with rickets, and has been regarded by some 
observers not as a separate disease, but as a complication or 
manifestation of this disorder. This, however, is probably 
not true, as it is sometimes seen in infants who show no 

1 Arch. f. Kinderheilk., August 31, 1920, 68, 1 and 2. 
402 



SPASMOPHILIA 403 

signs of rickets. It occurs most commonly in poorly nourished 
infants who have had trouble with their feeding, and is especially 
likely to be seen in those who have been fed on proprietary 
foods, or on any mixture excessively high in carbohydrate and 
poor in the other food elements (cf. Rickets). 

The seasonal incidence is very striking. It is most com- 
mon in the winter and spring, and only rarely occurs during the 
summer months. In a series of 246 cases collected by Wilcox,* 
74 per cent, occurred during the months of January, February, 
March, and April. The highest incidence (24 per cent.) was in 
March. 

Of 47 cases reported by McLean^ from the Out-patient 
Department of the Babies' Hospital, New York, none occurred 
during July, August, or September. There is some evidence 
to show that there may be a famihal tendency to spasmophiKa, 
but it is not a truly hereditary disease. 

Etiology. — Numerous theories of etiology have been pro- 
posed in the last fifteen years which would be tedious to review, 
and it is best to confine ourselves to the views held at the present 
time by the majority of authorities. 

The Parathyroids. — The parathyroid glands are small bodies 
which lie in the fatty and connective tissue about the thyroid, 
and are usually four to six in number. It is possible to produce 
a condition very similar to or identical with spasmophiKa in 
infants in experimental animals (dogs) by extirpation of these 
glands, or in human beings (adults) when the parathyroids 
have been inadvertently removed during the course of a thy- 
roidectomy. 

In experimental animals electric irritability of the central 
nervous system is increased, the blood calcium is lowered, and 
there may be carpopedal spasm in the same way that there is 
in naturally occurring spasmophiKa. Furthermore, the same 
methods of treatment apply to the one as to the other. Also, 
in a good many infants dying during a period of active spasmo- 

1 Amer. Jour. Dis. Chil., vol. 1, 1911. 

2 Arch. Ped., vol. 37, 1920. 



404 PRACTICAL INFANT FEEDING 

philia, old or fresh hemorrhages in the parathyroid glands are 
found, and this has led some investigators to the belief that 
abnormality of these bodies is the cause of the disease. How- 
ever, many autopsies show lesions of the parathyroids, yet the 
babies during Hfe have had no sjnnptoms of spasmophiKa. 
Furthermore, inasmuch as many spasmophiHc infants show 
no signs whatever of damage to the parathyroids,^ and as the 
condition may be produced in other ways quite independently 
of these bodies, it is the consensus of opinion that parathyroid 
insufficiency has little to do with spasmophilia as it is ordinarily 
seen. 

Calcium. — ^AU experimental and clinical evidence points to 
the fact that faulty calcium metabolism is the most important 
factor in the etiology of spasmophilia. One of the first observa- 
tions was the oft-quoted one of Quest,^ who found that the 
brains of spasmophilic infants contained less calcium than those 
of normal infants. 

A most significant fact is that the blood calcium is con- 
sistently low both in natural and artificially produced spasmo- 
philia. Howland and Marriott^ found that in normal infants 
and adults the blood calcium was constantly between 10 and 
11 milligrams per 100 c.c. sermn. In 18 cases of active tetany 
the average was 5.6 mgm. per 100 c.c. serum, a reduction 
of from 40 to 50 per cent, in nearly all cases. In convulsions 
not due to spasmophiKa the calcium content of the serum was 
foimd to be normal. These results have been confirmed by other 
observers. It has also been found that during the active period 
of tetany there is a considerably diminished retention of calcium, 
and that as the tetany disappears the calcium retention im- 
proves. ^>^ 

It is possible either in artificially produced or naturally 
occurring spasmophilia to relieve the active symptoms, and to 

1 According to Howland and Marriott (Quart. Jour. Med., 11, 289, 1918) 
parathyroid lesions are the exception rather than the rule. 

2 Jahrb. f. Kinderheilk., Ixi, 114, 1905. ^ Loc. cit. 
^ Schwartz and Bass, Amer. Jour. Dis. Chil,, vol. 3, 1912. 

^ Brown and Fletcher, Amer. Jour. Dis. Chil,, vol. 10, 1915. 



SPASMOPHILIA 405 

bring about a more normal nerve irritability by the adminis- 
tration of calciiun salts. 

The Relation of Sodium to Spasmophilia. — ^The sodium ion 
acts as a nerve irritant, and excess of this ion in the blood can 
bring about such an increased irritability as to cause spasmo- 
philia. 

Rowland and Marriott^ report 3 typical cases of tetany 
caused by intravenous injections of sodium bicarbonate for 
acidosis. 

Morse/ likewise, reports the case of a girl who was given 
large doses of sodium bicarbonate at one time, and a considerable 
amount of sodium phosphate another time for the treatment of 
a long-standing pyelitis. Both times she developed typical 
and severe tetany. Her renal function was found to be very 
poor, with an extreme fixation of specific gravity and a very 
low phthalein test. At autopsy her kidneys were much atrophied 
and showed typical chronic ' 'interstitial nephritis.'' The func- 
tion of the kidney was so poor that the sodium salts given could 
not be excreted, but were retained in the blood, and increased 
nerve irritability to such an extent as to cause tetany. A similar 
case has been reported by Grulee,^ and he likewise points out 
the fact that whey, which is rich in sodium salts, when fed to 
spasmophiHc infants may precipitate an attack of tetany or 
general convulsions, or may make an already existing tetany 
worse. 

The Interrelationship of Sodium and Calcium. — It is probable 
that faulty calcium metabolism alone is not the cause of spasmo- 
philia, and that the significant fact is the ratio in the blood- 
serum between the calcium, on the one hand, and the sodium 
on the other. Calcium is a nerve sedative, sodimn a nerve 
irritant, and in order to maintain the correct degree of nerve 
irritability there must be a definite ratio between the amount 
of calcium and of sodium in the blood. Increased sodium or 

1 Loc. cit. 

2 N. Y. Med. Jour., No. 25, December 18, 1920. 
•Amer. Jour. Dis. Chil., vol. 13, 44, 1917. 



406 PRACTICAL INFANT FEEDING 

diminished calcium cause an increased nerve irritability, i. e., 
spasmophilia. This disturbance of equiHbrium is brought about 
by faulty metaboHsm in bottle-fed babies suffering from certain 
digestive disturbances. The exact mechanism of its production 
is obscure. This theory has been advocated especially by Brown 
and Fletcher.^ It is probably not far from the truth, and has 
considerable experimental and clinical evidence to support it. 
The fact that the blood calcium is low, that feeding calcium 
salts either to dogs with experimental tetany or to infants with 
spasmophiHa reduces the nerve irritabihty, and that sodium 
salts either by mouth or intravenously greatly increase it, which 
has been shown by numerous investigators, are all strong argu- 
ments. Brown and Fletcher have also shown that in the active 
stage of spasmophilia there is a great storing up of sodium and 
potassium in the body, and a loss of calcium and magnesium,^ 
and that when the S3rmptoms begin to improve these conditions 
are reversed. They believe that free diuresis and free action 
of the bowels are very important in getting rid of sodium and 
potassium, and record several cases in which there was great 
improvement coincident with a diarrhea, during which there was 
probably a sweeping out of these elements from the body. 

Symptoms. — Spasmophilia may be latent, with no symp- 
toms except an increased mechanical and electric nerve irrita- 
bility, or it may be active, when it is manifested by laryngismus 
stridulus, tetany, or general convulsions. SHght causes of irri- 
tation, such as indigestion, teething, or acute respiratory infec- 
tions, which would probably cause no nervous disturbance 
in a normal infant, may be enough in a spasmophilic baby to 
convert the latent condition into the active. 

Signs of Increased Nerve Irritability. — ^The so-called "Chvos- 
tek" sign or ^ ^facial phenomenon" occurs in most cases, whether 
latent or active, and is one of the most practical and rehable 

* Loc. cit. 

2 Rowland and Marriott have found that the magnesium content of the 
blood in spasmophilia is normal, and believe that this element has little to 
do with it. 



SPASMOPHILIA 407 

diagnostic signs that we have in spasmophilia. It consists of a 
quick contraction of the small muscles about the mouth, nose, 
or temporal region, when the facial nerve is lightly tapped, 
either with the finger or with a small percussion hammer, in the 
middle of the cheek just under the malar bone. Escherich^ 
records this sign in three degrees as follows: 

1. A slight twitching at the angle of the mouth or of a small 
muscle bundle in the nose or forehead. 

2. A strong twitch at the corner of the mouth, alas nasi, 
or labialis or frontalis muscles. 

3. A definite twitch in all the muscles suppKed by the facial 
nerve. 

The Peroneal Sign. — This sign is elicited by tapping lightly 
over the peroneal nerve at the head of the fibula on the outside 
of the leg. A quick outward jerk of the foot follows. 

Trousseau's Sign. — If the upper arm or leg is constricted by 
compressing the limb with a tourniquet, typical carpopedal 
spasm may result. In our opinion this is not a very valuable 
sign, as it is absent in many cases of spasmophilia, and it is not 
of enough value to subject the baby to the discomfort and possi- 
ble danger of carpopedal spasm. If it occurs it is, however, 
pathognomonic. It is not a necessary sign for the diagnosis of 
spasmophilia, and I have given up even trying for it on accoimt 
of the reasons given above. 

Electric Irritability. — Increased irritability of the nervous 
system as measured by the response (usually of the peroneal 
nerve) to stimulation by the galvanic current is the most char- 
acteristic, constant, and reliable finding in spasmophilia. This 
is known as Erb's phenomenon. The determination of the 
electric reactions is undoubtedly the most accurate method of 
diagnosing the condition and of following the results of treat- 
ment. It is not an especially complicated test to perform by 
those who are familiar with it, but requires a certain amount 
of electric apparatus and considerable practice before reliable 
results can be obtained. It is for use in hospitals and by pedi- 
* Quoted by Holmes, Amer. Jour. Dis. Chil., vol. 12, i, July, 1916. 



408 PRACTICAL INFANT FEEDING 

atrists who are seeing many cases of spasmophilia, or who are 
especially interested in the subject. 

It is not practical for others to use, and it is quite possible 
to diagnose and to treat active spasmophilia successfully with- 
out it. Therefore, as I do not wish to bore the average reader 
by filling up space in the middle of a chapter with something 
that is of no practical value to him, I have discussed the electric 
reactions in an appendix at the end of the chapter. 

Active Symptoms of Spasmophilia. — The most common active 
symptoms are: 

1. Laryngismus stridulus. 

2. Tetany. 

3. General convulsions. 

Spasm of the bronchial musculature ("bronchotetany") has 
also been observed. 

Laryngismus Stridulus. — This is a frequent and character- 
istic manifestation of spasmophilia. It consists of a spasmodic 
contraction of the laryngeal muscles, and in the mildest cases is 
manifested merely by a crowing sound during inspiration, when 
the child is laughing or crying. In somewhat more severe cases 
there is a momentary cessation of respiration, accompanied by 
a slight degree of cyanosis, and followed by the characteristic 
"crow." In the most severe cases the symptoms may be ex- 
tremely alarming. The attack of apnea comes suddenly, pre- 
ceded by a short intake of the breath. Cyanosis is marked, the 
baby struggles for the breath it cannot get, and loses conscious- 
ness if the period of apnea lasts more than a few seconds. There 
may be also associated general convulsions. After a few seconds, 
in most cases, the spasm relaxes, the breath is drawn in with a 
crowing sound, and consciousness returns. In rare cases the 
spasm may be so severe that intubation or tracheotomy is 
necessary, and death has been reported. 

Attacks of laryngismus stridulus may be very frequent, often 
as many as thirty or forty in the twenty-four hours. 

Tetany or carpopedal spasm consists of a tonic contraction 
of the hands and feet. It may or may not be accompanied by 



SPASMOPHILIA 409 

general convulsions. The position of the extremities is quite 
characteristic, the hands being flexed at the wrists, turned to 
the ulnar side, with the thumb drawn across the hand toward 
the little finger. The feet are extended on the legs, and the toes 
are tightly flexed. 

There is usually evidence of considerable pain during the 
spasm, especially if one tries to unclinch the hands, and some- 
times the backs of the hands and feet may be considerably 
swollen. There is usually no loss of consciousness during carpo- 
pedal spasm unless general convulsions occur along with it. 
The spasm ordinarily lasts from a few minutes to a few hours, 
but may continue for several days or even weeks. It occurs in 
by no means a large proportion of spasmophilic cases, but when 
it does occur is pathognomonic. 

General Convulsions. — General convulsions represent one of 
the most common manifestations of spasmophilia, and may 
occur with laryngismus or tetany or, more commonly, alone. It 
is probably true that the majority of repeated convulsions 
occurring in infants under two years of age are manifestations 
of spasmophilia. Some exciting cause is usually necessary, 
such as the onset of an acute infectious disease, teething, indi- 
gestion, etc. There is nothing especially characteristic about 
spasmophilic convulsions, except that a great many may occur 
in the course of twenty-four hours, and that there is sometimes 
an associated tetany. 

Bronchial Tetany. — This condition is probably more common 
than is generally realized. 

It was first described by Lederer^ in 1913, who gave it the 
name "bronchial tetany." Curschmann soon after described 
certain other cases of a somewhat different type from those of 
Lederer.2 Short papers by Rietschel and by Wieland appeared 
in 1913 and 1914, but aside from this very little has been written 
regarding it. Lederer saw 58 cases of spasmophilia among 5903 
ambulatory and 767 ward patients; 6 of these showed "bronchial 

1 Ztschr. f. Kinderheilk., 1913, Bd. 7, 51. 

2 Munch. Med. Woch., 1914, Ixi, No. 6. 



4IO PRACTICAL INFANT FEEDING 

tetany/^ His patients were all under six months of age and all 
of them died. In most of his cases there was continued spasm 
of the bronchioles, probably lasting until death, and giving rise 
to pulmonary atelectasis, cough, cyanosis, and rapid respiration. 
According to Lederer the condition most likely to be confused 
with bronchial tetany in infancy is pneumonia. it:-Ray of the 
chest is of the greatest value in diagnosis, and serves to differ- 
entiate the two conditions. The atelectasis is caused by tonic 
spasm of the bronchial smooth muscle, which shuts off the air- 
supply to the alveoli supplied by that particular bronchial tube. 

Since the condition of spasm may last for days, weeks, or 
months, the air in the shut-off alveoli is absorbed, the walls 
collapse, and that portion of the lung becomes atelectatic. In 
Lederer's cases there was dulness over certain portions of the 
chest, which seemed sharply demarcated, while over the rest of 
the chest there was likely to be emphysema. The bronchial 
spasm may be continuous or intermittent, and in one case seen 
by us^ the intermittent attacks of spasm somewhat resembled 
whooping-cough. 

General Condition of Spasmophilic Infants. — ^The nutri- 
tional condition is never normal, although sometimes these 
children may appear fat, and may be of normal weight, or even 
above it. The flesh is not firm, however, nor is the color good. 
In most cases the baby is obviously undernourished and suffering 
from indigestion. The most common type of indigestion seen is 
probably chronic fat indigestion. 

Diagnosis. — ^The diagnosis should not be difficult in most 
cases. The Chvostek sign is present in about three-quarters of 
all cases, and if present in children under two years of age is 
pathognomonic. According to Holmes^ it is highly suggestive 
under four or five years, but may occur in mild degree in normal 
children of over three years. 

The appearance of tetany is quite characteristic, and can 
hardly be confused with anything else. 

1 Med. Clin. North America, September, 1920. 

2 Loc. cit. 



SPASMOPHILIA 411 

Laryngismus stridulus, likewise, is such a striking condition 
that it should not ordinarily be mistaken. The two conditions 
with which it might be confused are congenital laryngeal stridor 
and breath holding due to temper. 

Congenital laryngeal stridor sounds a good deal like laryngis- 
mus stridulus to the inexperienced observer. It is probably 
caused by a congenital narrowing of the epiglottis,^ and gives 
rise to a noisy inspiration sometimes, but by no means always, 
accompanied by crowing. The noisy inspiration is continuous, 
however, and not spasmodic, as it is in laryngismus stridulus, 
nor is it accompanied by cyanosis, loss of consciousness, or 
convulsions. 

Breath holding h common in certain highly strung children. 
It is usually brought on by attacks of temper, when the child 
has been crossed in some way. He starts to cry vigorously, 
begins to get red in the face, then blue, and finally becomes 
limp and stops breathing for a moment, sometimes with a loss 
of consciousness, sometimes without. The period of apnea is 
only of short duration, and he soon "catches his breath." There 
is no crowing inspiration, no convulsion, and the attacks come 
on almost invariably following a display of "temper." These 
characteristics should easily serve to differentiate the two con- 
ditions. 

It should practically always be possible to diagnose active 
spasmophilia without the use of the electric reactions. In 
latent cases and in certain active cases manifested by convul- 
sions, but not by tetany or by laryngismus stridulus, when the 
Chvostek sign is negative, the determination of the electric 
reactions is necessary in order to make a certain diagnosis. 
These are, without doubt, the most reliable diagnostic criteria 
of spasmophilia, but, as we have said before, are not practical 
for average use (see Appendix). 

Prognosis. — Spasmophilia is not without danger to life, as 
occasionally a child with largygismus stridulus or general con- 
vulsions may die. The prognosis as to cure should be good in 
^ Morse, Case Histories in Pediatrics, Boston, 1920. 



412 PRACTICAL INFANT FEEDING 

the vast majority of cases, as there are fairly satisfactory methods 
of treatment. 

It is possible, however, that considerable permanent damage 
may be done to the central nervous system, and some clinicians 
believe that spasmophilic children who have suffered from re- 
peated convulsions are never quite normal mentally. 

Treatment. — Of the Active Manifestations. — ^A spasmophilic 
convulsion is treated in much the same way as any other con- 
vulsion would be. A good sized dose of castor oil should be 
given, and the lower intestine emptied by an enema. It is 
likely that these things will have been done before the doctor 
arrives. The next thing to do is to relieve the convulsion. 

This may be done in any one of three ways: 

Chloral. — ^The rectal administration of chloral is probably 
the most generally satisfactory way of controlling convulsions. 
Even small infants bear it well, and it works quickly, usually in 
about twenty minutes. I always carry in my bag a solution of 
chloral hydrate containing 5 grains to the teaspoonful, and give 
it mixed with a little warm milk high into the rectum with a 
glass syringe and a small rectal tube. It is usually well retained 
if the buttocks are held together for fifteen minutes or so after 
administration. The dose is relatively large, partly on account 
of the method of administration, partly because large doses are 
needed to overcome the extreme nervous irritability which is 
present. An initial dose of 5 grains is usually not too much for 
a well-grown baby of seven months, and another dose half the 
size of the first should be repeated in half an hour if the first 
has not taken effect. Despite the fact that it is well borne by 
even young infants, chloral is not a drug that can be used care- 
lessly, as it is sometimes very depressing to the circulation. I 
have seen the heart rate drop to 12 to the minute following a 
moderate sized dose of chloral to a baby of six months. The 
heart rate should, therefore, always be carefully watched, and 
camphor or brandy given if it is much lowered or shows signs of 
irregularity. 

Ether or Chloroform. — The inhalation of a small amount of 



SPASMOPHILIA 413 

ether or chloroform is a vei}' efficient method of controlling 
convulsions, and works more quickly than does chloral. On 
account of the danger to the heart in infants from chloroform, 
and the possibility of starting up a respiratory irritation (par- 
ticularly in rachitic children) with ether, my personal preference 
is for chloral. 

Morphin. — Subcutaneous injections of morphin are likewise 
efficient, but I never like to use this drug in children under two 
years of age, as they are very susceptible to it, and doses which 
would not be considered at all large may cause poisoning. 

Inasmuch as almost all children who have spasmophilia are 
under two years, it has not, in my opinion, a very wide applica- 
tion in this disease. It is, however, recommended by several 
good authorities. 

Carpopedal spasm may often be relieved by a hot soak in the 
tub at about 110° F. If this does no good, chloral may be used 
in the same way that it is in general convulsions. 

The subcutaneous injection of magnesium sulphate is said 
to be very efficient in controlling carpopedal spasm, although I 
cannot vouch for it from personal experience, ha\dng never had 
occasion to try it. 

It was first used by Berend,^ who injected 20 c.c. of an 8 
per cent, solution into the subcutaneous tissue of the buttocks. 
It has since been used by a number of other students of spas- 
mophilia -^dth apparently good results, and no bad ones, save a 
moderate amount of discomfort at the site of the injection. 
One injection is usually enough to control the spasm, but it 
may be necessary to repeat it again the next day. Its efi'ect is 
not of long duration, and its use applied only to the control of 
the active manifestations, and not to the correction of the 
amderlying disorder of metabolism. 

It is certainl}^ worth a trial either in obstinate tetany or in 
general con\ailsions which do not respond to other methods of 
therapy. 

Laryngismus Stridulus. — Slapping the baby on the back or 
i Monatschr. K. finderheilk., Orig. 12, 1913-14. 



414 PRACTICAL INFANT FEEDING 

throwing cold water in his face often relieves laryngismus stridu- 
lus. In severe cases it may be necessary to undress the baby 
and dip him alternately in warm and cold water, or in rare cases 
artificial respiration, tracheotomy, or intubation may need to be 
resorted to. 

General Treatment of the Underlying Condition. — The 
whey of cow^s milk aggravates spasmophilia; breast milk cures it. 

For twenty-four to forty-eight hours after severe convul- 
sions, tetany, or bad attacks of laryngismus no milk should be 
given, but the baby should be fed on a cereal gruel with sugar 
added if desired, but no salt. It is of the utmost importance 
to keep the bowels moving freely either by the use of castor 
oil or milk of magnesia, and it is also probably of some importance 
to promote a free diuresis. The fluid intake shoiild, therefore, 
be pushed. 

In the treatment of spasmophilia there is nothing to be 
compared to breast mQk, and for the permanent feeding a wet- 
nurse should be secured if possible. The manifestations of spas- 
mophilia are so terrifying to the parents that they are usually 
glad to do anything that promises rehef, and a diet of breast 
milk almost always relieves the active manifestations. Some- 
times it acts almost like a miracle, and I well remember one 
infant of seven months who had been having repeated convul- 
sions for several weeks. He never had another after breast 
feeding was begun. It may be said that breast milk is almost 
a specific, and that there are but few cases in which a preven- 
tion of the occurrence of active symptoms cannot be expected. 

If it is not possible to secure a wet-nurse, artificial feeding 
is carried on according to the general principles of infant feeding. 
It is important to correct any existing disturbance of digestion, 
and after this has been done the spasmophilic condition may 
change from the active to the latent t3^e. It is very important 
not to feed a mixture rich in whey, as the sodium and possibly 
potassium salts of the whey tend to increase nerve irritability, 
and thus to aggravate the spasmophilia. A cream and precipi- 
tated casein mixture contains only small amounts of whey 



SPASMOPHILIA 415 

salts, and may be of service for a while, although it might not 
be suitable for continued administration. The addition of 
cereal and of vegetables to the diet should be begun as early 
as possible; cereal at the sixth or seventh month, and vegetable 
purees at the eighth or ninth. The sodium content of the diet 
must be kept low, therefore meat soups, which contain consider- 
able amounts of sodium salts, should not be used, and no salt 
should be added to any cereal or vegetable puree that is given. 

The baby must not be allowed to be constipated, and it is 
well, for a while, to put a teaspoonful of milk of magnesia in the 
day's feeding as a routine. 

Drugs. — Calcium therapy is of very definite value in most 
cases, as might be expected from the nature of the disease. 
Most students of spasmophilia who have had experience with 
this praise it highly, and it is probable that those who have not 
secured good results have used too small doses. 

Marriott and Howland,^ who are perhaps somewhat more 
enthusiastic on the subject than the majority of clinicians, 
say, ^'Calcium has a very prompt effect in preventing aU the 
S3rmptoms of active tetany, and if present they almost always 
disappear in thirty-six to forty-eight hours. The electric reac- 
tions also change, so that a cathodal opening contraction with 
a current of less than 5 miUiamperes is no longer obtained. The 
calciima content of the senmi also rises, but in most cases does 
not come quite back to normal. We know of hardly another 
drug which acts with the promptness and the regularity that 
calcium does in tetany." 

Method of Administration. — ^Large and frequent doses are 
necessary in order to flood the system with calcium, and to 
keep it so flooded. Either calcium chlorid or calcium lactate 
may be used, the former usually being preferred on account of 
its greater calcimn content. Calcium chlorid exists in two forms, 
the crystalline, which contains only about 18 per cent, of calcium, 
and the fused, or anhydrous, which contains 36 per cent. Cal- 
ciimi lactate contains about 13 per cent. As it is the calcium 

^Loc. cit. 



41 6 PRACTICAL INFANT FEEDING 

content of the drug in which we are chiefly interested, the an- 
hydrous salt is what should be written for, and if the crystalline 
form of calcium chlorid or calciimi lactate is used it is neces- 
sary to give twice as much in order to secure the same amount 
of calcium contained in half the amount of the anhydrous chlorid. 
Good results cannot be secured without large doses, and there- 
fore from 10 to 15 grains of the anhydrous chlorid should be 
given four or five times a day to begin with, and may be reduced 
as the active symptoms of spasmophilia subside. It can be 
given in the milk, or its somewhat unpleasant taste is perhaps 
better disguised if it is given in orange juice. 

i^. Calcium chlorid (anhydrous) .. . Six; 

Water ad. Bvj.— M. 

S. — One teaspoonful five times a day in milk or orange juice. 

Calcium treatment should be continued for a considerable 
period until the tendency to spasmophilia has entirely dis- 
appeared. It is well usually to continue it until May or June 
(Rowland and Marriott), but the dosage need not be always 
so large as at the beginning of treatment. If the chlorid upsets 
the stomach, the lactate may be used instead, but must be given 
in very large doses in order to secure results. Its taste is not 
unpleasant, it is readily soluble, and is best given in powdered 
form mixed with the baby's milk. About 120 grains a day should 
be given. According to Bachenheimer,^ a heaping teaspoonful 
of powdered calcium lactate weighs about 75 grains; thus about 
IJ teaspoonfuls divided between the different feedings would 
be the correct daily dose. 

Cod-liver Oil and Phosphorus. — Inasmuch as rickets is so 
constantly associated with spasmophilia, cod-liver oil and 
phosphorus should be given, and it is possible that this may 
help not only the rickets but also the spasmophilia by causing 
an increased calcium retention. 

The Electric Reactions. — ^The apparatus necessary consists 
of a battery, a milliamperemeter, a switch for reversing the 
1 Monatschr. f. Kinderheilk., Bd. 14, 1916. 



SPASMOPHILIA 417 

polarity of the current, a rheostat for controlling its strength, 
and two terminal electrodes covered with absorbent cotton 
moistened in salt solution. 

The inactive electrode is applied over the abdomen, the 
active over the peroneal nerve as it winds about the head of the 
fibula, on the outside of the leg. The current is then made or 
broken, first with the cathode and then the anode as the active 
electrode. According to Wilcox the test for cathodal closure 
should be made first, as response to this occurs most readily. 
Then the anodal closure, anodal opening, and cathodal opening 
should follow in order. It is best to begin the tests with a 
strength of current sufficient to produce a muscular response, 
and then to reduce it gradually to the point at which the response 
fails. According to Wilcox one hand should be kept over the 
foot, as it is often possible in this way to feel a slight twitch 
when it cannot be detected with the eye. 

Response to the electric reactions varies considerably, 
according to the age of the child, and even from day to day 
in the same child, so it is not always possible to tell definitely 
what is normal and what is abnormal by any absolute 
standard. 

According to Holmes, who has most thoroughly studied the 
electric reactions in normal and spasmophilic infants and chil- 
dren of various ages, the following is the correct interpretation: 

Cathodal Opening. — A cathodal opening contraction with 
less than 5 ma. of current is pathognomonic of spasmophilia 
in children under five years of age. 

Anodal Opening. — An anodal opening contraction appearing 
with a current less than that causing an anodal closing contrac- 
tion, and less than 5 ma., is pathognomonic in almost all cases 
during the first six months of Hfe. Its appearance with a current 
of less than 2 ma. is probably pathognomonic up to the fourth 
or fifth year. 

Cathodal Closing. — The cathodal closing contraction is almost 
always obtained with a current of less than 5 ma. in normal 
children under six months, and after this time it is regularly 
27 



41 8 PRACTICAL INFANT FEEDING 

present with a current of less than 5 ma. It is, therefore, of no 
value in the diagnosis of spasmophilia. 

Anodal closing contraction usually requires more than 5 ma. 
in infants less than six months old. From then up to two years 
the A. C. C. is frequently, and after two years regularly, obtained 
with a current of less than 5 ma. An anodal closing contraction 
with a current of less than 5 ma. is, therefore, suggestive in the 
first six months only. 

The only two really important reactions are the cathodal opening 
and the anodal opening, and of these two, the former is the more 
important. As a summary it may be said that if the cathodal 
opening contraction occurs with less than 5 ma., or if the anodal 
opening is less than the anodal closing, and less than 5 ma., spas- 
mophilia is present. 

For a more complete discussion of the electric reactions, see 
the following references : 

Holmes, Amer. Jour. Dis. Chil., vol. 12, 1, July, 1916. 
Rowland and Marriott, Quart. Jour. Med., 11, 289, 1918. 
Wilcox, Amer. Jour. Dis. Chil., vol. 1, June, 1911. 
Reye, Arch. Ped., 31, 1914. 
von Meysenburg, Amer. Jour. Dis. Chil., vol. 21, 1921. 



CHAPTER XIX 

SCURVYi 

Infantile scurvy is a disease of nutrition probably de- 
pendent upon the prolonged lack of some essential element in 
the diet. It is characterized especially by a weakened or inef- 
ficient condition of the endothelial lining of the blood-vessels, 
which predisposes to hemorrhage, especially under the peri- 
osteum of the long bones, into the skin and mucous membranes, 
and from the kidney. Barlow^ in 1883 was the first to emphasize 
the fact that infantile scurvy is a distinct disease. Its occurrence 
had been noted long previously, but it was usually considered 
an acute manifestation of rickets. It occurs frequently in con- 
junction with this disease, but probably bears no relationship 
to it. It is the same disease as adult scurvy. 

Occurrence. — Scurvy is not at all an uncommon disease, and 
is apparently on the increase. Its incidence in the Out-patient 
Department of the Children's Hospital, Boston, from 1904 to 
1913 was found by Morse^ to be as follows: 

Year. Percentage of scurvy cases. 

1904 0.11 

1905 0.43 

1906 0.17 

1907 0.33 

1908 0.24 

1909 0.24 

1910 0.47 

1911 0.61 

1912 0.67 

1913 0.87 

^ For the most exhaustive account of scurvy yet pubhshed in any language 
see Dr. Alfred F. Hess's fascinating monograph, "Scurv^^, Past and Present," 
to which I shall often refer in this chapter. 

^Abstr. Proc. Roy. Med. and Surg. Soc, London, n. s. 1, 102, 1883. 

3 Boston Med. and Surg. Jour., 1914, clxx, p. 504. 

419 



420 PRACTICAL INFANT FEEDING 

Glendenning/ in a study of the out-patient records for 1916-20 
from the same hospital, found that the incidence for these five 
years averaged about 1 per cent., a considerable increase over 
Morse's figures. 

This increase is probably due to the fact that more babies 
are being fed on heated milk than was formerly the case, and 
undoubtedly the disease is much more prevalent than even 
these figures show, as many latent or subacute cases pass unrec- 
ognized. It is not a disease of poverty or poor hygiene, and is 
as common in the well-to-do as in the poor — according to some 
authors, more so. It is a disease which can be prevented, and 
which should not occur at all if the baby is being fed intelli- 
gently. Season apparently has very little influence on its occur- 
rence, nor has the previous nutritional state of the child. It is 
confined almost entirely to bottle-fed babies, but may occur 
exceptionally in the breast fed. It is most common in the 
second half of the first year, but occurs not infrequently in the 
first half of the second year, and rarely in older children. The 
youngest case in the American Pediatric Society's oft-quoted 
report (1898) was at three weeks; the youngest case seen by 
Hess was at 4J months. ^ In none of Still's 54 cases was the age 
under five months.^ 

Etiology. — ^All experimental and clinical data indicate that 
scurvy is caused by the lack of some essential element in the 
diet rather than to the presence of some harmful element, to a 
faulty proportion of fat, carbohydrate or protein in the diet, 
or to other factors. At the present time the general opinion is 
that it is due to the lack of a specific vitamin, which has been 
called "water-soluble C" or the antiscorbutic vitamin. This 
view is supported by much evidence, both experimental and 
clinical. Our modern knowledge of this disease dates from 1912, 
when Hoist and Frohlich^ produced it in guinea-pigs by limiting 

1 To be published. 

2 Scurvy, Past and Present (Hess). 

3 Brit. Med. Jour., July 28, 1906. 

* Ztschr. f. Hygiene u. Infectionskrankheiten, 1912, vol. Ixxii. 



SCURVY 421 

the diet to grain, and cured it quickly by the addition of fresh 
vegetables. Since then we have learned a great deal more about 
it, largely through the efforts of Hess and McCoUum and their 
collaborators in this country. Scurvy in infants occurs espe- 
cially with three sorts of food: proprietary foods, condensed 
milk, and heated milk, either boiled or pasteurized, all foods 
which are not ''fresh," and in which the antiscorbutic vitamin 
is lacking. It is easily cured in many cases by simply substi- 
tuting a diet of fresh raw milk for the pre\dous food, or still 
more quickly and with more certainty if orange juice or a vege- 
table is added. It is probable that it is necessary for a baby to 
take a vitamin-poor diet over a considerable period of time 
before manifest scurvy develops, according to Hess about six 
months. Active scurvy represents, however, the end-result of a 
long-continued lack of the antiscorbutic \dtamin in the diet, 
and probably long before this condition appears there is a state 
of poor nutrition present (of "latent" scurvy). 

The antiscorbutic vitamin occurs in fruit juices, in vege- 
tables, in germinated pulses and cereal grains, in meat (espe- 
cially glandular organs), and in milk. It is the most sensitive 
and unstable of the three vitamins, and in milk especially is 
easily destroyed by heat, alkalinization, aging, drying, or oxida- 
tion. Its exact chemical composition is unknown, and it has 
not been isolated in a pure state. 

Milk is rather poor in antiscorbutic vitamin, and consider- 
able quantities must be taken in order to protect from scurvy, 
according to Hess, at least a pint daily. It is therefore possible 
for scurvy to develop on a diet of raw milk if not much is taken; 
100 c.c. of fresh raw cow's milk is equal in antiscorbutic power 
to only about 3 c.c. of orange juice,^ and as Hart, Steenbock, 
and Ellis^ have shown, the vitamin content of the milk is directly 
proportional to the vitamin content of the cow's fodder. They 
found that summer pasture milk was much more potent as an 
antiscorbutic than dry feed milk or winter-produced milk, 

1 McCollum in Nelson's Loose Leaf Medicine. 

2 Jour. Biol. Chem., 1920, xlii, 383. 



422 PRACTICAL INFANT FEEDING 

involving the ration of corn, ensilage, or sugar mangels. This, 
then, may be a factor in the production of scurvy. Although 
cow's milk is not rich in the antiscorbutic factor, it is not at all 
common to see scurvy in babies who have been taking raw milk. 
It is common, however, on a diet of boiled or pasteurized milk. 
It is possible, however, for babies to be fed on boiled milk for a 
long period of time without developing scurvy, and without the 
addition of an antiscorbutic, provided the milk is fresh to begin 
with and is used soon after being boiled. If boiled milk were 
the most important cause of scurvy, one would expect it to be 
very common in France and Germany, where all milk fed to 
infants is boiled as a routine. Such, is, however, not the case, 
and Hess^ quotes Variot, who during twelve years distributed in 
his out-patient department 400,000 quarts of sterilized milk, 
heated in J-liter bottles and sealed at the farm, without ever 
having had a case of scurvy develop. According to Hess, other 
factors may be just as important as boiling, and prolonged 
heating at a lower temperature, as in pasteurization, may be 
more deleterious to the antiscorbutic vitamin than the higher 
temperature reached when milk is boiled for a few minutes. 
The freshness of the milk has a great deal to do with it, and 
Hess is of the opinion that the aging incident to pasteurization 
is fully as important as the heat in the destruction of the anti- 
scorbutic power of the milk. Oxidation is another factor which 
he considers important, and in most of the methods of com- 
mercial pasteurization there is ample chance for this to take 
place. 

Thus it may be said that stale^ heated milk, whether boiled 
or pasteurized, predisposes to scurvy. It has also been shown 
that the antiscorbutic vitamin is especially sensitive to alkalin- 
ization. This may be of considerable practical importance if 
the baby is being fed on a food to which an alkali has been 
added, such as sodium citrate or potassium carbonate (malt 

* Amer. Jour. Dis. Chil., November, 1917, vol. 14. 

2 This means merely milk which is not fresh; it does not mean sour or 
putrid milk. 



SCURVY 423 

soup). Faber^ showed that potassium citrate even in a con- 
centration of 0.25 per cent, was able to diminish or destroy 
the antiscorbutic power of cow's milk. Hess and linger- have 
also found that milk to which alkali (potassium carbonate) 
has been added will not protect against scurvy as efhciently 
as does milk without the addition of an alkali, and that the 
antiscorbutic principle in orange juice is made inefficient by 
being rendered twentieth normal alkaline to phenolphthalein. 
Individual predisposition probably has something to do with 
the development of scurvy, and cases are on record where one 
of twins developed it, while the other, who was fed on exactly 
the same diet, did not. There is no good evidence to show that 
infection, indigestion, or constipation play any role in the 
etiology. 

It may he said as a summary that infantile scurvy is caused by 
a lack of the antiscorbutic vitamin in the diet. This lack may be 
brought about by feeding proprietary foods or condensed milk, 
which are notably lacking in the vitamin, or by using too little raw 
milk in a weak milk modification, or by using milk in which the 
vitamin content has been lowered by boiling, pasteurization, aging, 
or alkalinization. 

Although fully developed scurvy is a hemorrhagic disease, 
the clotting power of the blood is only slightly diminished, and 
even this is not constant.^ The number of platelets is within 
normal limits. There is, however, always an anemia of the ordi- 
nary secondary type, which may occasionally be severe. The 
metabolism shows nothing of especial interest or importance. 

Signs and Symptoms. — Scurvy should be regarded not as an 
essentially acute disease, but as a long-continued nutritional 
disturbance, which may exist for months before characteristic 
hemorrhagic symptoms develop. 

Hess especially has insisted strongly upon this, and has 
called attention to what he calls ''latent" and ''subacute" scurvy. 

1 Proc. Soc. Exper. Biol, and Med., N. Y., 1919-20, xvii, p. 40. 

2 Jour. Amer. Med. Assoc, November 1, 1919, vol. 73. 

3 Hess and Fish, Amer. Jour. Dis. Chil., 1914, vol. 8, pp. 386-405. 



424 PRACTICAL INFANT FEEDING 

The latent condition represents the earhest stage, and is 
difficult to recognize. 

''When about six months of age the baby has ceased to thrive, 
to gain satisfactorily, to look strong, or to eat as we should desire. 
The most careful physical examination has failed to solve the 
difficulty. On the other hand, the history of a diet of heated 
milk and lack of antiscorbutic food, considered in conjunction 
with the pallor and lack of appetite, the increased knee-jerks, 
and perhaps the cardiorespiratory syndrome (increased pulse 
and respiration rate, see below) has awakened suspicion, and 
has led us to prescribe orange juice with a view to diagnosis as 
well as treatment. The result frequently has been magical.''^ 

''Subacute" scurvy is somewhat more definite. The baby 
does not thrive, and fails to gain, or gains only a little, despite 
a diet which fulfils his caloric needs. He is irritable, has a poor 
appetite, and perhaps has slight edema of the eyelids. The 
papillae at the tip of the tongue are congested and prominent, 
and there may be seen an occasional petechial spot over the 
body. There may be slight tenderness of the legs, especially to 
pressure, and the knee-jerks are markedly exaggerated. There 
is likely to be enlargement of the heart, especially to the right, 
which shows well by the x-ray, but which may be difficult to 
detect by percussion. The pulse and respiration are especially 
important, according to Hess. Both are considerably increased 
in rapidity, the respiration relatively more than the pulse, and 
there may be a rapid drop in both soon after orange juice is 
given. The urine may contain a few red blood-cells or albumin. 
The bones may show by the x-ray slight periosteal hemorrhages, 
or the "white line" of Frankel (see below). Such a picture may 
go on for some time before active scurvy develops, and is usually 
not recognized. 

Active Scurvy. — When the scorbutic process is well developed 
well-marked signs and symptoms occur. The usual story is that 
babies who have been fed on proprietary foods or heated milk, 
without the addition of orange juice, develop a marked tender- 

* Jour. Amer. Med. Assoc, vol. Ixviii, January 27, 1917 (quotation, Hess). 



SCURVY 425 

ness of the legs, and cry with pain every time they are moved. 
This is the most common symptom — often the only one — and is 
usually sufficient upon which to make a diagnosis of scurvy. 

An interesting analysis of the first symptom noted by the 
mother was made from the records of 93 cases by Morse^ in 1914 

as follows : 

First Symptom Noted 

Crying on handling 69 

Paresis 11 

Swelling of legs 5 

Abnormality of gums 2 

Ecchymosis 1 

Bloody urine 2 

Failing 1 

Condition discovered at hospital 2 

Some of the most important signs and S3miptoms are the 
following, which, however, are not likely to occur all together in 
the same case: 

General Symptoms. — The state of nutrition may be poor or 
good, according to what the child has been previously fed on. 
The average case does not, however, show evidences of severe 
malnutrition, but the flesh is always flabby and the color poor. 
The child is extremely fretful and irritable, and shrieks with 
pain every time he is moved. There is usually no associated 
gastro-intestinal disturbance, but there may be sometimes 
looseness of the bowels. The appetite is poor, a condition which 
does not usually come on suddenly with the other acute symp- 
toms, but has been present for some time while the scurvy was 
developing. The temperature is more likely to be normal than 
elevated, but not uncommonly reaches 101° or 102° F. If it 
continues for any length of time after orange juice therapy has 
been started, there is probably some compHcating infection 
present. Scorbutic babies are very susceptible to infection, and 
for this reason care should be taken, especially in a hospital 
ward, that they are not exposed to respiratory infection. Pye- 
litis is not an uncommon complication. 

^ Loc. cit. 



426 



PRACTICAL INFANT FEEDING 



There may be a "rosary" which is very similar to a rachitic 
rosary except that the beading is more angular. That this is 
a true manifestation of scurvy, and not caused by a complicat- 
ing rickets, is shown by the fact that it rapidly disappears when 
orange juice is added to the diet (Hess). 

The legs are practically always tender, usually exquisitely 
so, so that the slightest movement or pressure causes the most 
severe pain. The tenderness is caused by subperiosteal hemor- 
rhage, which occurs most commonly in the lower portion of the 
femora (Fig. 25). There may be no swelling apparent if the 
hemorrhage is not extensive, but if it is extensive there may be a 
great deal of swelling, noted especially on the front of the thighs or 




Fig. 26. — Characteristic position of the legs in scurvy. Note also exoph- 
thalmos. 



lower legs. This may feel very hard if the hemorrhage is of long 
standing and has begun to organize, and there are cases on 
record where an operation has been performed, mistaking the 
swelling for a bony tumor. If the tenderness is well marked, 
motion is so painful that there is likely to be a pseudoparalysis, 
and the baby lies in a characteristic position, with the legs 
everted (Fig. 26). It is very rare for hemorrhage to occur 
within the capsule of a joint, but there may be hemorrhage 
into the loose tissue about the joint. The tenderness is, however, 
almost always of the shaft of the bone and not of the joint. 
Fractures at the lower third of the femur or tibia are not un- 
common, and there may be separation of an epiphysis. Sub- 




\ ■ 



Fig. 25. — Infantile scurvy. Section of femur showing subperiosteal 
hemorrhages with periosteal bone formation. There are hemorrhages in the 
bone-marrow and distortion of the line of ossification at the lower end. 
(MacCallum.) 



SCURVY 427 

periosteal hemorrhage may also occur in the bones of the arm, 
but is not at all common. 

Hemorrhage in Other Localities. — The Skin. — Petechial hemor- 
rhages into the skin and mucous membranes are common, and 
should always be carefully looked for, as they are often of great 
value in diagnosis. They are most common on the hard palate, 
on the upper part of the back and neck, on the chest, and more 
often on the upper than on the lower extremities (Hess and Fish). 
I recall one case a few years ago in which the tenderness of the 
legs was only very slight, and the suggested diagnosis was con- 
firmed by a few small petechial spots hidden behind the ear, 
the only other physical sign present. In some cases the hemor- 
rhages in the skin may be more extensive, and resemble the 
large "black-and-blue" spots so often seen in purpura. 

The Gums. — ^A spongy, hemorrhagic condition of the gums 
is common, and is a valuable diagnostic sign. This is seen 
usually only when teeth are present, and is most likely to occur 
about the central upper incisors. There is a turgid, purplish 
swelling of the mucous membrane of the gum about the teeth, 
which is rather soft and tender, and which bleeds easily. It is 
almost always present in well-developed scurvy if the teeth 
have come through, but in a few cases it may be lacking when 
weU-marked signs of scurvy are present in other localities. In 
some cases the hemorrhagic condition of the gums may be evi- 
denced only by a thin red line or a smaU patch behind the tooth, 
and may be easily overlooked (Still^). In severe, long-standing 
cases the gum condition may be serious, and extensive ulcera- 
tion and slough may be present. While it is not common to 
observe disturbance of the gum if no teeth are present, it may 
be seen in some cases if the teeth have come down so far that 
they are near the surface of the gum. 

The Urine. — Blood in the urine is not at all uncommon, 
and in a few cases may be the first symptom noted. Any baby 
during the second half-year showing this symptom should always 
be suspected of having scurvy, until it is proved to be due to 

1 Brit. Med. Jour., July 28, 1906. 



428 



PRACTICAL INFANT FEEDING 



other causes. Occasionally the blood is visible macroscopically, 
so that the urine is colored bright red, but far more often it 
is normal in appearance macroscopically, and a few red cells 
are seen under the microscope. The urine is also likely to be 
considerably diminished in quantity during the acute stage, 




Fig. 27. — Exophthalmos with edema and extravasation of blood into the 

eyelids. 

and a marked diuresis may be seen after the administration of 
orange juice as the child improves. 

Exophthalmos. — Hemorrhage under the periosteum of the 
orbital plate of the frontal bone occurs occasionally, giving rise 
to exophthalmos. This usually comes on suddenly, and is one 
of the most striking rare manifestations of scurvy. It may be 
unilateral or bilateral, most commonly the former, and may 



SCURVY 429 

be of such a degree that the eye Hterally bulges from the head. 
The eyelids are usually more separated than normal on account 
of the eyeball which bulges between them, but if there is a good 
deal of extravasation of blood and edema of the lids the eye 
may be closed, as is shown in Fig. 27. There may be 
sometimes merely a swollen discolored condition of the lids 
without exophthalmos. The exophthalmos of scurvy comes on 
much more suddenly than any other form of exophthalmos, 
which should serve to differentiate it from other conditions; 
also it is in most cases easily cured by the addition of orange 
juice to the diet, and in a few days the eye resumes its normal 
position. 

The Digestive Tract. — Hemorrhage from the digestive tract 
is not common, but small amounts of blood may occur in the 
stools. 

The Circulatory System.— As Hess has pointed out, the 
heart is almost always enlarged, especially to the right. This 
may sometimes be detected by percussion, but is more accurately 
determined by x-ray examination. The blood practically always 
shows a secondary anemia, which may be of severe degree. 
This is probably very slow in its development, and one of the 
characteristic things about ' 'latent" scurvy is the pallor. The 
blood-vessels are weakened, allowing extravasations of blood, 
which accounts for the hemorrhage. In order to demonstrate 
this Hess and Fish^ devised the ^'capillary resistance test." 
An ordinary blood-pressure arm band is attached to the arm. 
The pressure is raised to 90 and is held there three minutes. 
The band is then removed, and when the cyanosis has faded, 
examination is made for petechial spots below the constriction. 
They found that most scurvy cases showed many petechias, 
and normal subjects did not. Normals may, however, show a 
few petechias just below the pressure band which are of no signifi- 
cance. The pulse and respiration are increased sometimes to a 
considerable degree, and the increased pulse particularly may 
persist for a considerable period after the baby has been appar- 

1 Loc. cit. 



430 PRACTICAL INFANT FEEDING 

ently cured of scurvy. The respiration is increased relatively 
more than the pulse, and instead of the normal 1 : 4 ratio, the 
ratio may be 1 : 3 or 1 : 2 (Hess) . 

Diagnosis. — The diagnosis of well-developed scurvy is not at 
all difhcult if one is familiar with the disease. The chances are 
that any baby from the age of six to eighteen months has scurvy 
who begins suddenly to have pain in the legs and to cry when 
handled. If, added to this, some of the other signs of scurvy 
are present, such as spongy gums, petechial hemorrhages into 
the skin, or blood in the urine, the diagnosis is unmistakable. 
Despite its characteristic symptomatology, scurvy is a disease 
which is often overlooked or wrongly diagnosed simply because 
the practitioner is not familiar with it. In 37 cases seen by 
Morse^ in consultation, from 1909 to 1914, the disease was 
recognized by the attending physician but four times. The 
most frequent diagnoses made were rheumatism, acute nephritis, 
and poliomyelitis. Syphilitic epiphysitis and osteomyelitis are 
two other diseases not infrequently mistaken for scurvy. 

The differential diagnosis between scurvy and these five 
conditions is not difficult in most cases. 

Rheumatism. — Babies very seldom have rheumatism. It 
occurs most commonly between the age of four and twelve years. 
The youngest case I have myself seen was at two years. Fur- 
thermore, in rheumatism the tenderness is about the joint and not 
in the shaft of the bone, as it is in scurvy. The temperature 
would be more likely to be elevated in rheumatism, and the 
other signs of scurvy would not be present. Despite the fact 
that rheumatism practically never occurs in small babies, this 
is the mistake most commonly made in the diagnosis of 
scurvy. 

Syphilitic Epiphysitis .—This condition almost always occurs 
before the age of five months, scurvy rarely does. Furthermore, 
the trouble is about the epiphysis and not in the shaft of the 
bone, as it is in scurvy, and practically always other signs of 
syphilis are present. If the diagnosis is in doubt, the Wasser- 

^ Loc. cit. 



SCURVY 431 

maiin test, x-ray, and therapeutic test should easily serve to 
differentiate the two conditions. 

Osteomyelitis is not common in babies of the age who would 
have scurvy. The septic appearance of the baby, high tempera- 
ture, leukocytosis, absence of other signs of scur\y, and the 
x-ray should make confusion unlikely. 

Poliomyelitis. — ^This disease is not infrequently confused 
with scur\y. In poliomyelitis there is not, however, the extreme 
tenderness seen in the former disease, the knee-jerks are absent, 
and in the acute stage there is usually a high fever. If in scur\y 
there were sufficient periosteal hemorrhage to cause pseudo- 
paralysis, enough to confuse the condition mth pohomyelitis, 
there would ahnost certainly be some swelhng of the leg and 
other signs of scur\y present elsewhere. If there is still doubt, 
limibar puncture or x-ray should clear it up. 

Acute Nephritis. — If a baby has blood in the urine, with 
other symptoms of scur\y also, there is no danger of confusing 
scurvy wdth acute nephritis. If, however, the only definite sign 
consists of a Kttle albumin and a few red blood-ceUs in the 
urine microscopically, the dift'erential diagnosis may not be 
easy. There are certain points of differentiation, however. In 
the first place, if a small baby has acute nephritis, he usually is 
fairly sick with it, and has considerable albumin in the urine, 
with many casts and red cells in the sediment. Edema would 
probably also be present, and there would probably be also a 
history of some previous infection to account for the nephritis. 
The history of the previous diet of the baby is of considerable 
importance: if he has been recei\dng an adequate amount of 
fresh raw milk, with as much as a tablespoonful of orange juice 
a day, he certainly is not suffering from scur\'y. If he has been 
on a scurvy -producing diet, and has gradually been faiHng, is 
pale, and has a poor appetite, the chances are that he has scurvy. 
If after these considerations it is impossible to decide, the 
therapeutic test (2 tablespoonfuls of orange juice a day) will 
make the diagnosis in a few days. 

The x-Ray Diagnosis. — The x-ray is often valuable in giving 



432 PRACTICAL INFANT FEEDING 

confirmatory evidence for the diagnosis of scurvy. The outline 
of the epiphysis is quite distinct in contradistinction to its 
appearance in rickets, and this alone should serve to distinguish 
the two conditions (Lovett). There may be considerable bone 
atrophy, which is uniform along the whole shaft of the bone. 

There is likely to be at the end of the diaphysis the so-called 
''white line" of Frankel, which was formerly thought to be 
diagnostic of scurvy. It may also occur in rickets, however. 
It is due to an increased density of bone at the end of the di- 




Fig. 28. — Well-marked "white line." Arrow indicates slight elevation of the 

periosteum. 

aphysis. The ''white line" may be seen early in the disease, some- 
times before any evidence of periosteal hemorrhage is visible, 
and is likely also to persist for a considerable period after the 
clinical symptoms have subsided. It is, therefore, of some diag- 
nostic value in early cases, provided rickets can be ruled out. 
The most characteristic feature seen in the rr-ray appearance of 
the bones in scurvy is the hemorrhage. In mild cases this may 
be manifested simply by a Httle thickening or bulging of the 
periosteum, or in more severe cases by most extensive irregular 



SCURVY 



433 



shadows indicating blood-clot which has involved the soft tissues 
(Figs. 29,30). 






J 



Fig. 29. — Separation of epiphysis of femur, also large blood-clot. 



Prophylaxis. — The prophylaxis of scurvy is of the utmost 
importance, and, what is more, is successful. If a baby is 
properly fed, scurvy should not occur. 

In spite of the fact that boiled and pasteurized milk pre- 



28 



434 PRACTICAL INFANT FEEDING 

dispose to scurvy, this does not outweigh the great advantage 
obtained from their relative freedom from bacteria, and it is 
easy enough to give an antiscorbutic. Every baby taking 
pasteurized or boiled milk should be started on orange juice 




Fig. 30. — Large blood-clots of both femur and tibia 

as soon as he is three months old, and it is probably not pos- 
sible for any baby who is taking daily an adequate amount of 
this most potent antiscorbutic to develop the disease. What 
constitutes an adequate amount is not certain, but probably 



SCURVY 435 

2 tablespoonfuls a day is enough, and this is the quantity that 
it is best to use. I have recently seen a number of cases of 
scurvy where the mother said that she had been giving the 
baby orange juice, but on closer questioning it was found that 
the baby did not like it very well, so perhaps only as much as a 
teaspoonful three or four times a week had been taken. I have 
never seen a case where as much as a tablespoonful has been 
given every day. Babies usually take orange juice readily. 
It is best given about one hour before the feeding, twice daily, 
in doses of 1 tablespoonful at a time. It may be diluted or 
sweetened with cane-sugar, if the baby takes it more readily 
in this way, and if it causes "sour stomach" with regurgitation, 
which it may do occasionally, it may be diluted with a little 
lime-water just before administration. In a very few babies 
orange juice causes looseness of the bowels, but these are very 
few and far between, and, as a matter of fact, orange juice does 
not deserve at all the reputation it has as a laxative; in most 
cases it is entirely without action on the bowels. In the rare 
cases where orange juice is not well borne, canned tomato 
juice or potato soup can be used (see below). Green vegetables, 
such as spinach or carrots, have but little place in the pro- 
phylaxis of scurvy in infants, as their antiscorbutic power is 
low, and it would be necessary to take relatively large amounts 
in order to secure any effect. 

Is it necessary to give orange juice to babies who are tak- 
ing raw milk? It probably is not necessary in the vast majority 
of cases, provided an adequate amount of milk is taken, but in 
view of the fact that even raw milk may vary a great deal in 
its antiscorbutic power, it is well to give orange juice to every 
baby as a routine. It is common, when a barley- or oat-water 
diluent is being used in the milk formula, for the mother to add 
boiling hot diluent to the milk; then it stands for a considerable 
period of time, slowly cooling, and although I have no idea 
what the temperature of such a mixture would be, I have seen 
several cases of scurvy when the milk was not boiled or pasteur- 
ized, where this seemed to be important as a causative factor. 



436 PRACTICAL INFANT FEEDING 

Treatment and Prognosis. — There is no therapeutic procedure 
in medicine where more striking and rapid results are obtained. 
If a boiled or pasteurized formula has been used, this should be 
discontinued and a raw formula of the same strength substituted, 
or if a proprietary food has been the previous diet, the baby 
should be put at once on a suitable raw milk modification. 
In many cases this would suffice to cure the condition, but 
results are so much more brilliant and rapid if orange juice is 
added that one would not try to treat scurvy without it. An 
ounce a day is sufficient, given half in the morning, half in the 
afternoon, an hour before the feeding. In practically all cases 
the acute symptoms will be much improved in forty-eight hours, 
and at the end of about four days should have practically sub- 
sided. Results are so certain that, if improvement does not take 
place, there should be considerable doubt that the baby has 
scurvy. Although the acute symptoms subside rapidly, the 
bone changes, the anemia, and the rapid heart action may per- 
sist for some weeks, and it may be some time before the baby 
is in first-class condition. In addition to the orange juice it is 
well to give 3 grains of the saccharated oxid of iron three times 
a day in order to aid in the correction of the anemia. It is need- 
less to say that the baby should be handled as little as possible 
while his legs are tender, and that small doses of paregoric 
should be given to make him comfortable, if necessary. The 
prognosis is almost always good, provided the condition has 
not progressed too far. If no treatment is given, the baby 
slowly wastes away and dies from weakness and malnutrition. 
In long-standing, exceptionally severe cases, even orange juice 
may be unavailing, and Holt records 4 deaths out of 100 cases. 
In the extreme type of case, where the stomach may be so irri- 
table that orange juice cannot be retained, it may be given intra- 
venously, apparently with good results. The orange juice is 
boiled five minutes, is made neutral or slightly alkaline by means 
of N/1 NaOH just before administration, and 10 c.c. is given 
intravenously each day for several days (Hess). 

Antiscorbutic Foods. — The antiscorbutic vitamin exists in all 



SCURVY 437 

fruit and vegetable juices, germinated cereal grains and pulses, in 
glandular animal tissues, such as liver, kidney and pancreas, and 
in milk. Non-germinated cereal grains contain no antiscorbutic 
factor, and muscle tissue contains so little as to be negligible. 

Orange, Lemon, and Lime Juice. — Orange and lemon juice 
are the most powerful antiscorbutics known. Lime juice is 
not nearly so powerful. Orange juice can be dried, preserved 
in the form of a powder, and it retains its antiscorbutic power. 
It can also be boiled and still remain potent, but if stored in the 
cold for three to six months it becomes inactive. Alkalinization 
for twenty-four hours likewise renders it non-potent; 3 c.c. 
of orange juice equal in antiscorbutic power about 100 c.c. of 
milk. The juice of orange peel is also markedly antiscorbutic. 

Tomato Juice. — Next to orange juice, tomato juice is an 
efficient practical antiscorbutic. Hess has used it extensively 
in an infant asylum, and has found it very satisfactory. He 
gives 2 tablespoonfuls of the juice from canned tomatoes daily 
to babies of oVer two months, and has noticed no ill effects 
from much larger doses. If oranges cannot be obtained, this is 
probably the best antiscorbutic to use. 

Potato. — ^Although adults depend largely upon potatoes as 
an antiscorbutic, they are not at all rich in the antiscorbutic 
principle, and it is necessary to take so much in order to secure 
an effect that potato is not at all important as a therapeutic 
agent for infantile scurvy provided orange, lemon, or tomato 
juice can be obtained. If these are unobtainable, potato-water 
should be used. One tablespoonful of mashed potato (the outer 
mealy layer from a boiled potato) is shaken in a pint of water 
in which the potatoes have been boiled, and the resulting gruel 
is used as a diluent for the milk modification.^ 

Carrots, grapes, apples, and bananas have only slight anti- 
scorbutic power. As a general thing the leafy vegetables have 
more potency than the roots and the tubers, and young vege- 
tables more than old. Cabbage is the most potent of all the 
vegetables. 

* McCoUum and Ruhrah, loc. cit. 



CHAPTER XX 
THE TREATMENT OF ECZEMA IN INFANCY 

Eczema is a very common condition during the first year of 
life, and often has a good deal to do with the feeding; hence its 
inclusion here. It may be divided into two broad types, the 
wet, or exudative, occurring usually in otherwise healthy, 
overfed babies, most commonly breast fed, or the dry type, 
which is more likely to occur in undernourished babies. It is 
not likely to start before the first month, and often shows a 
tendency to disappear spontaneously after the first year, 
although it may persist for years in many cases. The exact 
processes which go on in the body to produce eczema are not 
known, but it is certain that three factors are often operative: 

1. Local irritation. 

2. Overfeeding with fat or sugar, or in some cases with 
starch. 

3. Anaphylactic idiosyncrasy to foreign protein (most com- 
monly lactalbumin, casein, egg-white, or beef). 

The therapy in the present state of our knowledge is based 
upon these three etiologic factors. 

No good results can be obtained if the greatest attention to 
detail is not observed, and if the patient is not seen often. In 
severe cases the child should be seen every day. With pains- 
taking, intelligent treatment there is no case of eczema in infancy 
that cannot he greatly helped, and most cases can he cured entirely. 

In my opinion local treatment is of paramount importance, 
and the reason for most failures is that it is not carried out cor- 
rectly. It should be used, however, in conjunction with the 
other two measures. 

Local Treatment. — The essential thing to remember is that 
in any given case of eczema the condition may differ widely on 
various parts of the body, and that, therefore, it may be neces- 
438 



THE TREATMENT OF ECZEMA IN INFANCY 439 

sary to use several diflerent preparations at the same time for 
local application. For instance, what is suitable for a sebor- 
rheic scalp, is not at all suitable for an oozing eczema of the 
cheek or for a cracked eczema of the popliteal space. In most 
cases that one sees there usually are different types or stages of 
eczema on different parts of the body, and it is necessary, 
therefore, to know what sorts of application are suitable for 
each type. At the first \dsit I very frequently give the mother 
as many as three or four dift'erent preparations and teach her 
the name and special purpose of each, so that she will know, as 
she goes along from day to day, which one to use, according to 
the particular stage that the eczema happens to be in. This is 
of considerable importance, and it is of great value to teach the 
mother to recognize a seborrhea, a dry scaHng, or a weeping 
eczema, and to know which preparation to use for each type. 

In a general way the following are the types or stages of 
eczema that are seen, sometimes all in the same patient: 

1. Wet. 

2. Dry, very red, and acutely inflamed. 

3. Dry and rough, not acutely inflamed. 

4. Seborrheic. 

5. Intertriginous. 

6. Difluse papular or vesicular. 

7. Infected. 

Wet, oozing eczema is most likely to be seen in fat, overfed 
babies. It occurs especially on the cheeks, behind the ears, and 
in the pophteal and antecubital spaces. It begins usually as 
small, red, acutely inflamed papules, which soon coalesce, and 
finally begin to exude serum. Crusts may form, and under- 
neath the crusts the skin is raw and oozing. If in a locality 
where there are folds of skin, as in the pophteal space, large 
bleeding cracks may develop. 

Crude coal-tar is so successful in curing this type of eczema 
that it works in practically every case. There is nothing else 
that can approach it in efficiency, and since its introduction a 
few years ago the treatment of infantile eczema has been revo- 



440 PRACTICAL INFANT FEEDING 

lutionized, and where it used to take weeks of constant struggle 
to effect any improvement in a weeping eczema, it may now be 
controlled in most cases in a few days. Crude coal-tar is not 
the same thing as the ordinary wood tar of the Pharmacopeia, 
which has been so long used in the treatment of skin affections, 
and has nothing whatever to do with it. It is a by-product in 
the manufacture of coal-gas, and cannot be obtained from most 
retail druggists, but may be secured from many of the large 
drug houses, who get it from the coal distilleries. Different 
''lots" of crude coal-tar vary considerably, as there is no stand- 
ardization of the product, and not infrequently one may get a 
shipment of tar which is not good. A good crude coal-tar should 
be of an inky black color and of a very thick consistency, so 
that it will barely run out of a bottle. It should be perfectly 
smooth and should contain no granules whatever. This is the 
preparation to use in every moist case of eczema, except where 
there is infection or on the scalp. It is not used where there is 
infection, as it may make it worse, and it is not suitable for use 
on the scalp, because it makes a sticky mess with the hair. 

Method of Use. — The crude tar is painted over the raw sur- 
face twice a day by means of a cotton swab on the end of a throat 
stick. After it dries, which usually takes only a few minutes, a 
dusting-powder may be applied, but is not necessary. The 
skin is painted in this way morning and night until the oozing 
has been stopped, which rarely takes over two or three days. 
It should not be removed with olive oil, vaselin, or anything 
else, but should be allowed to wear off gradually, which does not 
take long. When it has worn off, a rather smooth, red, and 
tender new skin is seen underneath, which is very easily irri- 
tated if rubbed or scratched. At this stage a bland protecting 
ointment is used, such as either one of the following: 

I^. Bismuth subcarbonate 5ij; 

Lime-water q. s. 

Anhydrous lanolin ad. Sij. — M. 

^- f^^'^^J aa 5ii; 

Zmc oxid j 

Vaselin ad. §ij. — M. 



THE TREATMENT OF ECZEMA IN INFANCY 44I 

Tar contains a certain amount of phenol, and there is a 
possible danger of toxic absorption if it is used on a large area 
of broken skin. In the ordinary case of eczema this does not, 
however, have to be considered, and I have never seen any ill 
results from its use. 

Dry, Red, Acutely Inflamed Eczema. — This type of eczema 
is perhaps the most common, and is likely to be seen on almost 
any part of the body. It may occur in small red papules of 
varying sizes, or in large patches, with sharply defined edges, 
or in diffuse irregular areas. Tar is also very efficient here, but 
is best used in the form of a paste. It should be applied twice a 
day, or if on an exposed place such as the face, where it is easily 
rubbed off by the baby, frequently enough so that there will 
always be present a fairly thick coating of the paste: 

I^. Crude coal-tar 3 J ; 

Zinc oxid 1 .. „.. 

starch )■■■ ^^ 5'^-' 

Vaselin ad. gij. — M. 

This paste is rather thick and of a blackish- brown color. It 
is very dirty, of course, and therefore old clothes should be 
used, or if the eczema is in a locality where bandages can be 
applied, these should be used. The best cloth as a bandage for 
eczema is old linen or cotton, which has been scorched in the 
oven. Scorched cloth is much less irritating to the skin than 
unscorched, and sometimes such a small detail as this may make 
a good deal of difference. 

If there is considerable induration or scaling of the skin, and 
the eczema is of long standing, the addition of 10 grains of 
salicylic acid to the ounce of ointment is of value. 

Dry, Rough, Not Acutely Inflamed Eczema. — For this type 
of eczema tar is not usually necessary, and it is possible to 
employ something that is less dirty. 

For very mild cases, where the skin is simply a little rough 
and dry, either plain lanolin or bismuth ointment are the best 
preparations. 



442 PRACTICAL INFANT FEEDING 

I^. Bismuth siibcarbonate 5ij ; 

Lime-water q. s. ; 

Anhydrous lanoHn ad. gij. — M. 



It is important to remember when using any ointment not 
to simply give directions to apply it two or three times a day, 
hut to apply it often enough so that the irritated surface will be 
continually covered by the salve, no matter how often it has to be 



If there is a good deal of roughening and thickening of the 
skin, the following is better: 

I^. Salicylic acid gr. xx; 

Zinc oxid 1 -- rr-- 

Starch / ""3.]; 

Vaselin ad. Sij. — M. 



Seborrheic Eczema. — This type of eczema, usually occurring 
on the scalp, is very common in small babies, and may be present 
when there is none on any other part of the body. It is usually 
called "cradle cap." It consists of many greasy scales and 
crusts. The best preparation to use on the scalp in most cases 
is ordinary boric ointment. This is applied very thickly, with a 
good deal of rubbing, twice a day, and then a turban made from 
an old handkerchief or towel is fitted to the head and kept there. 
Or with small babies it is usually simpler to have the mother 
get a few cheap cotton bonnets, and use these instead, as they 
fit better. It is very important to use a large amount of salve, 
to rub it in well, and to prevent it from being rubbed off by 
the use of a cap or turban. The boric ointment is applied every 
day, and no attempt made to remove it until the fourth day, 
when a gentle shampoo with castile soap is given, during which 
it will usually be possible to remove most of the seborrheic 
material. After this the boric ointment applications are con- 
tinued as before, with a shampoo twice a week. When the 
seborrhea is considerably better, and most of the scales have 
been removed, it is often well to shift to a salve containing 



THE TREATMENT OF ECZEMA IN INFANCY 443 

resorcin, which is often very efficient in finishing the cure, and 
in preventing the seborrhea from recurring : 

i^. Resorcin gr. xx; 

Vaselin ad. §ij.— M. 

For scalps with only a mild seborrhea or a dry scaling condi- 
tion a daily gentle rubbing with olive oil and shampoo three 
times a week usually is efficient, and keeps the skin in good 
condition. 

Intertriginous Eczema. — This type of eczema is usually seen 
on the inner side of the thighs, about the genitalia, symphysis 
pubis, and often extends up the abdomen as far as the umbilicus. 
It consists of an intense fiery redness, occasionally with con- 
siderable thickening, but with little scaling. It is not ordinarily 
moist, except as it occurs in very fat babies where two opposing 
skin surfaces come together, at the neck, under the armpits, etc. 
The fiery red, intensely irritated condition occurring on the 
inner side of the thighs and on the lower part of the abdomen is 
often rather difficult to treat, as it is impossible to keep it dry 
and to prevent irritation by urine and feces. It is probably 
caused in the beginning by irritation from urine, especially if it 
be strongly acid. The first essential in treatment is to prevent 
irritation in so far as possible. In order to accomplish this no 
diapers are to be used on the baby, and the lower part of his 
body is to be kept exposed to the air most of the time in a rea- 
sonably warm room. A thick pad of absorbent cotton is put 
between the legs to absorb urine when passed, and a diaper 
underneath to receive the stool. The cotton and diaper should, 
of course, be immediately changed as soon as they are dirtied. 
If the urine is strongly acid, enough potassium citrate is given 
in each feeding to make it slightly alkaHne; 10 grains usually 
suffices. Local applications are not so efficient as in some of the 
other forms of eczema. The best one to begin with is "white- 
wash": 

I^. Zinc oxid §j; 

Lime-water ad. § vj. — M. 



444 PRA.CTICAL INFANT FEEDING 

This is shaken vigorously, and applied every hour in liberal 
amounts, on soft scorched old cotton or linen cloths. 

If 'Whitewash" is unavailing, bismuth ointment or tar paste 
is used. In using a salve with this type of eczema it is better 
to spread it thick on pieces of soft scorched linen or cotton cloth, 
and then to apply these to the parts. If the irritated area can 
be kept reasonably free from urine and feces cure should be 
fairly rapid; if not, it may take a long time. Between skin 
surfaces, such as the axilla, folds of the neck and groin, this 
type of eczema, or intertrigo, is likely to be moist, and the 
treatment is somewhat different. The irritated areas should be 
cleansed once daily with warm lime-water, or a weak sodium 
bicarbonate solution, dried carefully, and liberally sprinkled 
with a dusting-powder, such as zinc stearate. It is of the great- 
est importance to prevent the two skin surfaces from coming 
together, and for this purpose small pledgets of absorbent cotton 
sprinkled with the dusting-powder are used. 

Diffuse Papular or Vesicular Eczema. — This occurs more 
frequently in children over eighteen months of age than in 
small babies. It comes on acutely, and is characterized by 
innumerable small vesicles or papules which are distributed 
evenly over the whole surface of the body, particularly the 
trunk. It is best treated by starch baths and tar paste. A 
rather thin solution of starch is made in the same way that one 
would prepare it for laundry purposes. In the morning the child 
is stripped and bathed all over with the starch solution, sopping 
it on gently. It is allowed to dry on. In the evening tar paste 
is applied and rubbed well into the skin with the flat of the hand, 
not using it quite so thickly as would be the case with a facial 
eczema. 

Infected Eczema. — If secondary pyogenic infection is present, 
as is not infrequently the case, this must be cleared up before 
improvement can take place. 

If the infection is diffuse, with a good deal of septic oozing 
and crusting, there is nothing so efficient as a 10 per cent, oint- 
ment of ammoniated mercury in vaselin. This should be used 



THE TREATMENT OF ECZEMA IN INFANCY 445 

frequently enough so that a thick coating of it will be over the 
infected areas all the time. If the infection is in the form of a 
few boils, which are especially likely to occur on the scalp, their 
contents are expressed and a 20 per cent, solution of silver nitrate 
applied to the cavity of the boil and to the skin in the immediate 
vicinity. Tar, or any thick paste, should never be used until all 
infection has subsided. 

If the reader will remember the following ten preparations, 
which have all been mentioned above, but are repeated in table 
form for the sake of clearness, and will learn how and when to 
use them, he will need no other local applications in the treat- 
ment of infantile eczema : 

1. Crude coal-tar. 

2. Tar paste: Crude coal-tar, 5ij; 

Starch J 

Vaselin, ad. gij. 

3. Lanolin. 

4. Boric ointment. 

5. 20 per cent, silver nitrate solution. 

6. 10 per cent, ammoniated mercury in vaselin. 

7. Starch paste: Zinc oxid 1 __ ^j. 

Starch J 
Vaselin, ad. Sij. 
Or the same, with gr. xx of salicylic acid added. 

8. Bismuth ointment: Bismuth subcarbonate, 5ij; 

Lime-water, q. s.; 

Anhydrous lanolin, ad. §ij. 

9. Resorcin ointment: Resorcin, gr. xx; 

Vaselin, ad. 5ij- 

10. "Whitewash": Zinc oxid, §ij; 

Lime-water, ad. 5vj. 

Prevention of Scratching. — If the child is continually scratch- 
ing there is no chance for the eczema to heal, and one night of 
scratching may undo the good results of a week of treatment. 
There are two good methods of preventing this. By the use of 



446 PRACTICAL INFANT FEEDING 

cuffs about 8 inches long of stiff cardboard, covered with cloth, 
which fit tightly over the elbows, and by preventing any flexion 
at the elbow, prevent scratching of the face. Cuffs do not, 
however, prevent scratching of other parts of the body, and it 
is always advisable in a bad case to use aluminum mittens as 
well. These are hollow cylinders of thin aluminum, which fit 
over the hands and fasten to the sleeve of the night dress. For 
all bad cases of facial eczema a mask with small holes for the 
eyes, mouth, and nose should be used. This is cut from old 
cotton or linen cloth, and should be kept on continuously while 
the eczema is acute. Mothers, as a rule, are very inefficient in 
handling eczema until they have had a considerable amount of 
instruction, and it is therefore essential to go over all details 
with them with a good deal of care at the first visit, and to see 
the child frequently in order to be sure that they are carried 
out. It is always a good plan to have a well-trained children's 
nurse for a while at the start of a bad case, and I cannot impress 
too strongly upon the reader that eczema in infants is a condi- 
tion where it is vital to pay careful attention to the smallest 
details in order to secure good results. 

Water is ordinarily irritating to the skin in most cases of 
eczema, and baths should not, therefore, be employed. The 
genitalia and buttocks may be cleansed with absorbent cotton 
and water; during the acute stages it is best to let the rest of 
the body alone. If caking of any paste used has taken place, 
or if crusting is excessive, it may be softened and removed with 
a little lanolin or vaselin. In general, it is best, however, to 
let any applications that have been made gradually wear off, 
rather than to remove them. 

When the eczematous condition is much improved baths 
may be given, and it is well with all infants who have a tendency 
to eczema to make the water less irritating by using bran or 
oatmeal. A cup of bran or oatmeal is put into a small cheese- 
cloth bag and stirred about in the bath water for a few minutes, 
so that it becomes milky. A superfatted lanolin soap should be 
used, which is much less irritating to the skin than ordinary 



THE TREATMENT OF ECZEMA IN INFANCY 447 

soaps, and it is well with all babies who have a tendency to 
eczema to give a lanoHn rub every day after the bath. 

If the face has a tendency to dryness or chapping after the 
acute stages of the eczema have been controlled, bismuth paste 
should be applied each time the baby goes out of doors, and 
especial care should be taken that the face is not exposed to 
cold, blustering winds. 

The Feeding. — Most babies with eczema are well nourished, 
indeed, it is the very fat, overfed breast baby who is most likely 
to have it, and improvement cannot usually be expected until 
the food is reduced in quantity or quality. It is always weU to 
secure a specimen of the breast milk for analysis if the baby is 
breast fed, and in a large proportion of cases the fat will be found 
too high, often from 4 to 6 per cent. The sugar may be also at 
fault, but its percentage in breast milk ordinarily varies but 
Httle. It is probable, when sugar is at fault, that the trouble is 
caused rather by too much food than too high a sugar percentage. 
The stools are likely to be rather oily, and usually show a large 
excess of fat under the microscope. In order to reduce the 
amount of food the feeding intervals are lengthened from three 
to four hours, nursing is permitted for only about eight minutes, 
and about 2 ounces of water or barley-water is given either 
before or after the breast feeding. The mother should be made 
to exercise, and should omit fats, potatoes, bread, desserts, and 
candy from her diet for a while. In this way it is often possible 
to considerably reduce the fat content of her milk. If all this 
is unavailing, there is some temptacion to wean the baby, but 
in most cases this is not advisable, as it is by no means certain 
that the eczema will improve on a diet of cow's milk. In cer- 
tain cases, however, weaning does cure the eczema, as I had 
brought out a few weeks ago. A large, overfed breast baby of 
three months began to lose his appetite and to have eczema on 
the face, arms, and scalp. There was a large amount of breast 
milk which showed 5.5 per cent, of fat. The mother was made 
to exercise, her diet was reduced, and the baby was given water 
before feedings — all to no avail. The eczema could be kept 



44^ PRACTICAL INFANT FEEDING 

under control by the use of local applications, but it was never 
possible to get rid of it entirely. The baby was finally weaned 
at the urgent request of the mother and was fed on a simple 
milk modification low in fat. In a very few days his eczema 
disappeared entirely without the use of local applications, and 
has never returned. If any food element is at fault when a baby 
fed on cow's milk has eczema it is most likely to be the fat, or 
more rarely the sugar. If fat is at fault, there may or may not 
be evidences of fat indigestion; if sugar is to blame, loose acid 
stools are usually present. If the baby is a fat, strong baby, 
in a good state of nutrition, feeding for a time on a fat-free or 
low fat food is desirable. He will probably lose some weight, 
but it will do him no harm, and his eczema is very likely to 
improve considerably. If the baby is not well nourished it is 
not advisable to reduce the fat in the food unless he is grossly 
overfed with fat, unless there are evidences of considerable fat 
indigestion, or the eczema is an unusually severe one. In most 
cases, however, the undernourished baby does not have a severe 
eczema, of the raw weeping type, and it is important for him to 
gain weight and to secure a better nutritional condition. There- 
fore the food should not be reduced, and it is possible to keep 
the eczema within reasonable limits by local treatment. As a 
matter of fact, in a good many of these undernourished babies 
with a dry, reddened, but not exudative eczema the condition 
shows a tendency to disappear as soon as the nutrition becomes 
better. In children over a year old, who are on a mixed diet, 
overfeeding with starch is not an uncommon cause of eczema, 
and the stools should be examined carefully to see if any evi- 
dences of starch fermentation are present. In this type of 
case there will usually be three or four mushy, foul stools a day, 
containing a large amount of undigested starch and cellulose. 
There is occasionally a chronic infection of the intestinal con- 
tents with the gas bacillus in these cases, which plays a part in 
the indigestion, and hence in the eczema. Such a child should 
be fed on a low fat and low starch diet, with lactic acid milk as 
its basis. 



THE TREATMENT OF ECZEMA IN INFANCY 449 

For some years Dr. C. J. White, Professor of Dermatology 
in the Harvard Medical School, has been sending me the stools 
of his eczema patients for examination, and, without quoting 
any exact figures, I should say that over half certainly showed 
some abnormahty of digestion, either fat, starch, or abnormal 
fermentation. It is always worth while to carefully investigate 
the condition of the digestive tract in any case of eczema. 
Sometimes indigestion seems not to be a factor, and changing 
the diet has no beneficial effects on the eczema; in other cases 
the results are brilliant. 

Idiosyncrasy to Food Proteins. — In some cases of eczema 
there is an anaphylactic idiosyncrasy to food proteins, the 
most common ones being the lactalbumin or casein of human 
or cow's milk, egg-white, or occasionally egg yolk, and the 
protein of beef. This idiosyncrasy seems to be the cause of the 
eczema, for when the offending protein is removed from the 
diet the eczema is improved or cured in most cases. 

It is, therefore, well worth while to endeavor to determine, 
in any case of eczema, especially with children on a mixed diet, 
whether any such idiosyncrasy exists, and while I do not agree 
with those who believe that most cases of eczema are due to 
anaphylactic idiosyncrasy, I still have seen enough cases where 
this was undoubtedly a factor to consider that the anaphylactic 
food tests constitute one weapon, at any rate, by which we may 
attack the disease. These tests are performed as follows: 

Small linear scratches about J inch long are made with a 
needle on the skin of the back, deeply enough to penetrate well 
into the skin, but not enough to draw blood. Then a small 
amount of the dried protein^ of the various foods to be tested 
is put on the scratch, a drop of 1/10 normal (0.4 per cent.) 
sodium hydrate added, and rubbed into the scratch with the 
protein powder. One scratch is left as a control, and has sodium 
hydrate added to it, but no protein. If any protein gives a 
positive test, in about fifteen minutes (less in many cases), an 
urticarial wheal at the site of the inoculation develops, which 

^ Proteins are furnished by the Arlington Chemical Co., Yonkers, N. Y. 
29 



4 so PRACTICAL INFANT FEEDING 

is surrounded by an area of erythema. Usually a positive 
reaction will give a wheal at least 0.50 cm. in diameter, but it 
is better to read the tests rather by their relation to the other 
scratches and to the control than by any standard size. If one 
wheal is considerably bigger than the reaction caused about 
any of the other scratches it should be called positive, even if 
it is not quite 0.50 cm. in diameter. Or if one scratch shows a 
large area of erythema without any wheal, and the other scratches 
show none, the test showing the erythema may be called positive. 
On very sensitive skins sometimes all the scratches will develop 
wheals of fair size, so it is rather in relation to the other scratches 
that we must interpret results than by any set standard. Dr. 
Joseph Grover and I have done some thousands of skin tests 
in the last two years on children with eczema and asthma, and 
we cannot help but feel that a great deal of caution is needed 
in interpreting these tests, and that, in general, those who have 
used them have been too eager to report positive reactions. 
If in a young breast-fed baby the test should be positive to one 
of the proteins of human milk, the baby should not be weaned, 
but the eczema should be treated locally, and the amount of 
milk taken by the baby somewhat reduced, in accordance with 
the directions given in the last section. 

If in a bottle-fed baby casein or lactalbumin gives a positive 
test, the amount of protein in the formula should be reduced to 
as low a point as is consistent with the baby's nutritional needs, 
and supplementary feeding of solid food begun as early as 
possible. If the idiosyncrasy is very marked it may be advisable 
to use goat's milk. If the eczema is in a very bad condition, 
temporary improvement may sometimes be secured by feeding 
the baby on a cereal and sugar diet for a few days, without any 
milk protein. This cannot, of course, be kept up for any length 
of time. We have seen comparatively few reactions to the 
proteins of milk, and in our experience beef and egg protein are 
the most common offenders. These last two are, of course, 
easily removed from the diet. In doing skin tests on breast-fed 
babies it is not infrequent to find that a positive test may be 



THE TREATMENT OF ECZEMA IN INFANCY 45 1 

obtained to some food (egg, cow's milk, beef) which the baby 
has never eaten. In these cases, according to O'Keefe,^ the 
sensitization has occurred through the breast milk, and if the 
foods which have given positive tests are omitted from the 
diet of the mother great improvement of the baby's eczema may 
take place. This is certainly worth taking into consideration 
in the treatment of eczema in the breast fed. 

1 Boston Med. and Surg. Jour., vol. 185, August 18, 1921. 



CHAPTER XXI 

PYLORIC STENOSIS AND SPASM 

Pyloric stenosis, or to give it its full name, "congenital 
hypertrophic stenosis of the pylorus," consists of an hypertrophy 
of the circular muscle-fibers of the pylorus, giving rise to obstruc- 
tion, with consequent projectile vomiting, rapid loss of weight, 
and final death from starvation if not relieved. 

Occurrence. — It is not an uncommon condition, but not 
much attention was paid to it until a comparatively few years 
ago. Martin, in Osier's "System of Medicine" (1908), says that 
"there are now more than 150 cases recorded in the literature." 
From 1914 to 1920 Downes, of New York, himself operated on 
217 cases. ^ These figures show how much more commonly it is 
now recognized than was formerly the case. 

For some unknown reason it occurs more frequently in 
males than in females, the ratio being about 4:1. It is seen 
more frequently in breast-fed than in artificially fed babies, the 
probable reason for this being that the majority of babies are 
fed on the breast during the first few weeks of life, after which 
period the symptoms of pyloric stenosis rarely make their 
appearance. 

Etiology. — The pyloric hypertrophy is undoubtedly congen- 
ital in origin, and a pyloric tumor has been observed in a seven 
months fetus (Dent) and in a number of infants a day or two 
old upon whom autopsies were performed. Its causation is 
obscure. According to Strauss^ it is caused by rhythmic con- 
tractions of the pylorus during fetal life, which start at that time 
due to some abnormal stimulation of the nerves of the stomach. 
The condition of hypertrophy, he believes, progresses during 

1 Jour. Amer. Med. Assoc, vol. 15, No. 4, July 24, 1920. 

2 Ibid., vol. 71, No. 10, September 7, 1918. 

452 



PYLORIC STENOSIS AND SPASM 453 

fetal life, but becomes greatly increased after birth, owing to 
the additional irritation produced by food. Wall,^ on the other 
hand, as do most other observers, believes that it is a simple 
developmental anomaly, and that any spasm which is present 
is secondary to the hypertrophy. He does not believe that 
"any muscular contraction would be able to produce such a 
large, hard mass of tissue" as the hyper trophied mass of muscle 
seen in these cases. 

Pathology. — The circular, smooth muscle-fibers of the py- 
lorus are hypertrophied, giving rise to an oval, hard, cartilaginous- 
Hke tumor, usually about the size of a small ripe olive. On 
section, the tissue of this tumor is whitish, porky, and non- 
vascular. The hypertrophy of the muscle-fibers causes narrow- 
ing of the pyloric orifice, and hence obstruction. This narrowing 
produces an infolding of the mucous membrane into rugae, and 
the opening at the pylorus in severe cases may be so small that 
it will admit only a fine probe. 

The walls of the stomach proximal to the pylorus are con- 
siderably thickened, and the stomach itself is usually dilated. 
The intestine in cases of average duration is small and col- 
lapsed, owing to the fact that it has received little food. 

Symptoms. — The important signs and symptoms are: 

1. Persistent projectile vomiting. 

2. Progressive loss of weight. 

3. Constipation. 

4. Visible gastric peristalsis. 

5. Palpable tumor. 

The obstruction may be complete or partial, the severity of 
the symptoms depending upon the extent of the obstruction. 
The baby is born apparently in good health, and does well for 
the first week or two, when he suddenly begins to vomit without 
apparent cause. The vomiting rarely begins before the end of 
the first week or after the sixth. At first there may be nothing 
especially characteristic about it, but it soon becomes explosive, 
and food may be forcibly ejected for a distance of a foot or two. 
i Arch. Ped., vol. 36. 1919. 



454 PRACTICAL INFANT FEEDING 

The vomitus shows no particular evidences of indigestion. The 
vomiting may occur immediately after feeding or in between 
feedings, and is usually constant, but not infrequently several 
feedings a day may be retained, in which case the next time the 
baby vomits the vomitus is larger than the amount of the pre- 
vious feeding. This is quite characteristic. The appetite is 
usually voracious, and these babies are almost always con- 
tinually hungry, and will take large amounts of whatever is 
offered them. 

In cases with almost complete obstruction severe constipa- 
tion is the rule; the stools are infrequent, very small, and may 
contain but little fecal material. They not infrequently some- 
what resemble meconium. 

Loss of weight is very rapid and large, and not infrequently 
as much as one- third of the body weight will be lost. With 
changes in food temporary improvement for a few days is likely 
to occur, but is not permanent. If untreated, the baby dies in a 
few weeks from starvation. 

Visible gastric peristalsis is an important sign and is present 
in practically all cases. It is best elicited by giving the baby 
an ounce or so of water, waiting a few minutes, and then gently 
scratching the skin over the stomach with a throat stick, when 
waves of peristalsis may be easily seen following each other from 
left to right across the abdomen. These waves in some cases 
may be as large as a small egg. 

The stomach is in most cases considerably dilated, and the 
dilatation is easily visible, giving rise to an undue prominence of 
the upper portion of the abdomen. 

Palpable Tumor. — Usually under the right conditions the 
pyloric tumor may be felt through the abdominal wall, most 
commonly sKghtly to the right and a little above the umbilicus, 
but occasionally high up under the edge of the liver. It takes a 
good deal of practice to feel a pyloric tumor on account of its 
relatively small size and on account of the fact that it is some- 
times difficult to secure sufficient relaxation of the abdominal 
wall. When it is felt it is a diagnostic sign of the greatest im- 



PYLORIC STENOSIS AND SPASM 



455 



portance. The absence of a palpable tumor does not, however, 
rule out pyloric stenosis. The tumor is best felt when the 
stomach is empty and when there is no gaseous dilatation of the 





Fig. 31. — Visible gastric peristalsis. 

stomach or intestines, and cannot be felt when the baby is 
crying, with consequent spasm of the abdominal muscles. In 




Fig. 32. — Visible gastric peristalsis. 



order to get rid of gas a small catheter may be passed into the 
stomach, and in order to secure relaxation of the abdominal 
wall a little water is given to the baby in a bottle while feeling 



456 PRACTICAL INFANT FEEDING 

for the tumor. If these conditions are present it may be felt, 
by experienced observers, in most cases. 

(The diagnosis, prognosis, and treatment of pyloric stenosis 
and pyloric spasm will be considered together.) 

Pyloric spasm consists of a spasm of the pyloric muscle, 
giving rise to much the same s3anptoms seen in pyloric stenosis, 
but to a lesser degree. The line between the clinical appearance 
of the two conditions is often not sharply defined, as in pyloric 
stenosis there is almost always some complicating spasm, and 
in pyloric spasm there may be enough hypertrophy of the cir- 
cular muscle-fibers or the redundant mucous membrane to give 
rise to a palpable tumor. 

Some authorities believe that there are not two separate 
conditions, but that all cases should be grouped under the head 
of pyloric stenosis, and considered under two groups, those 
with complete and those with partial obstruction. The weight 
of opinion, however, is that there are two separate conditions. 
This is borne out by the fact that in one group of cases the 
tumor at the pylorus is hard, non- vascular, and cartilaginous in 
character, while in the other group there may be no tumor at 
all, or if one is present it is soft and vascular, quite different from 
the tumor of true pyloric stenosis. The etiology of pyloric 
spasm is obscure; it may occur either in breast- or bottle-fed 
babies, but is more common in the latter. It is commonly seen 
in children of neurotic families, and besides the spasm of the 
pylorus there may be a hypertonicity of the voluntary muscles 
of the body as well, so that the baby holds his arms and legs 
very stiffiy. This has been especially emphasized by Haas,^ 
and since reading his paper I have noticed it in a number of 
cases. It is probably not far from correct to regard pyloric 
spasm as a result of gastric indigestion in a nervous baby. 

Symptoms of Pyloric Spasm. — ^We are dealing here with a 

functional, partial occlusion. The symptoms resemble those of 

true pyloric stenosis, but are not so marked. The baby is likely 

to be of a fussy, irritable type, easily frightened by noises and 

1 Arch. Ped., vol. 36, 1919. 



PYLORIC STENOSIS AND SPASM 457 

disturbed by handling. On the other hand, I have seen pyloric 
spasm in a baby who never cried and who always slept all 
night and a good part of the day. The vomiting is more inter- 
mittent, not so explosive, and the stomach is usually little if 
any dilated. It is not common for more food to be vomited 
than has been taken at the preceding feeding. Temporary 
improvement for a day or two is very likely to occur after a 
change in the food, the same as it does in pyloric stenosis. 

There may be a moderate degree of constipation, but never 
to the extent that is seen in pyloric stenosis, and the stools are 
always fecal. They are often green and undigested and may 
contain mucus. Visible peristalsis is more frequently seen 
than not, but may be absent. In a few cases a tumor may be 
felt, but this is the exception rather than the rule. 

Loss of weight is not so marked as in true pyloric stenosis, 
as a not inconsiderable amount of food reaches the intestines. 
Stationary weight or slight gains may be the rule, but if the 
condition persists, considerable loss may occur, and the baby 
may ultimately reach a severe degree of malnutrition. 

Diagnosis. — Pyloric stenosis and spasm are differentiated 
from simple indigestion with vomiting in that in the latter con- 
dition the vomiting stops when the food is regulated, and the 
evidences of obstruction, such as explosive vomiting, palpable 
tumor, etc., are not present. Visible peristalsis may be seen in 
rare cases. The Roentgen ray shows but little interference with 
the emptying time of the stomach. 

The diagnosis of pyloric stenosis when the obstruction is 
nearly complete is not difficult. The characteristic history, 
with explosive vomiting, small infrequent bowel movements, 
and marked loss of weight; the physical examination, with 
visible peristalsis and palpable tumor, form a picture which is 
definite and clear cut. A palpable tumor, is, however, not 
pathognomonic of stenosis, as it may be present in spasm when 
there is comparatively little obstruction. The chief difficulty 
is in determining the extent of the obstruction, which is essen- 
tial in order to decide upon the method of treatment to be 



458 



PRACTICAL INFANT FEEDING 




Fig. 33. — Immediately after eating. Fig. 34. — One-half hour after. 



\ 






4 





Fig. 35. — One hour after. 



Fig. 36. — Three hours after. 



Figs. 33 to 36. — Pyloric spasm, showing somewhat delayed emptying time, 
but by no means complete obstruction. 



PYLORIC STENOSIS AND SPASM 



459 




Fig. 37. — Immediately after eating. Fig, 38. — One-half hour after. 






Fig. 39. — One hour after. Fig. 40. — 2l hours after.* 

Figs. 37 to 40. — Pyloric stenosis, showing almost complete obstruction. 

' Not from the same case as Figs. 37—39. 



460 PRACTICAL INFANT FEEDING 

employed. The Roentgen ray, taken in conjunction with the 
clinical findings, is here of great value, and although it has 
been said by some that this method of diagnosis is of com- 
paratively little value, in my opinion it is invaluable, and gives 
us more accurate and valuable data as to the extent of the 
obstruction and the advisability of operation than do any of 
the other procedures which have been used for the same purpose, 
such as the passage of duodenal catheters or aspiration of the 
stomach contents. A feeding of about 2 ounces of a weak milk 
modification containing about a teaspoonful of bismuth sub- 
carbonate is given by gavage, and plates are taken immediately 
afterward, in one-half hour, one hour, two hours, and four hours. 
In many cases it is not necessary to take the last plate, as the 
first ones may give enough data on which to base conclusions. 
There is no need of taking plates later than four hours after the 
bismuth meal, although this is sometimes done as a matter of 
interest. The first plate, in a normal series, would show that a 
small amount of bismuth has come through, the second and 
third should show that a considerable amount has passed the 
pyloric orifice, the fourth, that most of the bismuth has gone 
through, while the last plate should show the stomach nearly 
empty. 

In pyloric stenosis with marked obstruction the first two 
plates usually show that no bismuth at all has left the stomach, 
the third and fourth, that most of it is still retained. 

With partial obstruction, the picture is different according 
to the amount of obstruction present. In most cases of partial 
obstruction, whether due to true stenosis of mild degree or to 
spasm, half or more than half of the bismuth is likely to have 
left the stomach at the end of four hours. In cases of simple 
indigestion the emptying time may be somewhat delayed, 
but most of the bismuth will have left the stomach at the end 
of four hours. 

In pyloric spasm the baby is more likely to be bottle fed 
than breast fed. The evidences of obstruction are not nearly 
so marked as in stenosis — the stools always contain considerable 



PYLORIC STENOSIS AND SPASM 46 1 

fecal material — a tumor is not likely to be felt, and if it is felt 
it is smaller, especially longer and thinner (Morse) than the 
tumor in pyloric stenosis, and may sometimes be felt to con- 
tract beneath the finger. The loss of weight is usually not ex- 
cessive, and there may be even a slight but unsteady gain. 
Visible peristalsis may or may not be present; it is practically 
always present in stenosis. The Roentgen ray shows some 
interference with the emptying time of the stomach, but it is 
never so marked as in true pyloric stenosis with nearly complete 
obstruction. 

Treatment of cases with extensive obstruction, where there 
is marked loss of weight, visible peristalsis, palpable tumor, and 
a large amount of the bismuth meal remains in the stomach at 
the end of four hours (true pyloric stenosis) . 

Although not a few competent observers have reported 
good results in this type of case with medical treatment, the 
consensus of opinion is in favor of operation. In my opinion 
true pyloric stenosis is a surgical disease, and operation should 
be done as soon as the diagnosis is made. It is of very great 
importance to operate when the baby is in good condition, and 
although there is a possibility that he may improve under 
medical treatment, the chances are against it, and much valuable 
time may be lost. Surgical intervention, as performed now, 
carries with it a comparatively low mortality, and is far ahead 
of medical treatment of any sort. It is probable that many of 
the cases of so-called pyloric stenosis that have recovered under 
medical treatment have, in reality, been cases of spasm. The 
operation usually performed up to about six years ago was a 
posterior gastro-enterostomy. This was a rather long, serious 
operation, and the mortality was high. 

The operation used now almost exclusively is the so-called 
Fredet-Rammstedt operation, or modifications of it, which con- 
sists simply in splitting the hypertrophied circular muscle- 
fibers of the pylorus down to the mucous membrane. This 
allows the mucous membrane to bulge out into the wound 
and overcomes the stenosis. The cure is permanent, and 



462 PRACTICAL INFANT FEEDING 

although the tumor may persist for a considerable time after 
the operation, the stenosis does not. The operation carries 
with it comparatively little shock, and a skilled operator can 
do it in twelve or fifteen minutes. 

The postoperative management is of great importance, and 
may mean all the difference between the life and death of the 
baby. It is especially important before operation to remove 
from the stomach any gas, mucus, and especially bismuth which 
may be still retained after the bismuth meal. I have only re- 
cently seen a case where the baby nearly died because he had a 
stomach full of bismuth which was not removed by gavage 
before operation. After operation it is well in much emaciated 
cases to give a subcutaneous infusion of normal saline (about 
150 C.C.). Stimulation with adrenalin, caffein, or brandy may 
also be necessary. 

Feeding is begun an hour or two after the baby comes out of 
ether, and it is of very great importance to secure breast milk if 
possible. About a dram of this may be given at first, diluted 
with an equal amount of water. For a few feedings it is given 
every hour. In the next few days the amount at each feeding, 
the strength, and the interval between feedings are increased, so 
that at the end of about two days an ounce at a feeding of 
nearly undiluted breast milk would be taken. It must be 
remembered that the intestine is in a collapsed condition and is 
not ready to receive much food ; therefore the feeding in the first 
few days must be very cautious. At the end of about a week 
the baby can be put to the breast. If artificial feeding has to 
be used, whey is the best thing to begin with. In the course of 
a day or two fat is added to this in the form of 16 per cent. 
cream, so that the baby would at first get 0.50 per cent, fat, 
then 1 per cent., and finally, after about ten days, 2.50 or 3 
per cent. As improvement continues and the baby becomes 
stronger the split protein feedings are discontinued, and a 
return to ordinary milk modifications is gradually made. 

Prognosis. — The prognosis depends very largely upon the 
general condition of the baby and upon how long the symptoms 



PYLORIC STENOSIS AND SPASM 463 

have been present. It is always doubtful in cases of long stand- 
ing; it should be uniformly good if operation is done within a 
week or two after vomiting has started. The case from which 
the Roentgen-ray plates were taken was operated on only three 
days after the beginning of vomiting. 

In 100 consecutive cases at the Babies' Hospital, New York, 
in which the vomiting had lasted less than four weeks, the 
mortality was only 8.7 per cent.-^ In those cases which had 
vomited more than four weeks it was 50 per cent. Kerley^ 
states that the mortality in infants who have not vomited for 
more than two weeks should not be over 5 per cent. 

In 78 consecutive pyloroplasties at the Children's Hospital, 
Boston, done by various members of the surgical staff, the 
mortality was 7.6 per cent.^ 

Porter^ reports 26 cases, all except 2 of which recovered. 
In Downes' large series of 217 cases'' there were 30 deaths, 
giving a mortality of 17.1 per cent. Almost all the babies who 
died had been vomiting for a long time and were in poor con- 
dition at the time of operation. 

Treatment of Pylorospasm or of Pyloric Stenosis with Compar- 
atively Slight Obstruction. — Treatment depends rather upon the 
extent of the obstruction than whether the condition is one of 
spasm or stenosis. Few cases of pylorospasm come to operation. 

It is always a question of nice judgment to determine whether 
or not cases with incomplete obstruction need operation. If 
loss of weight is not great, or if the baby has been holding his 
weight, if the stools are fecal, and fairly large and frequent, and 
particularly if the Roentgen-ray plates show that obstruction is 
relatively slight (about three-quarters of the bismuth meal 
having left the stomach at the end of four hours), it is advisable 
to try medical treatment. If after ten days or two weeks the 
vomiting is no better and the baby is losing weight, operation 

1 Holt (Discussion), Trans. Amer. Ped. Soc, vol. xxx, 1918. 

2 Ibid. 

3 Ladd: Surg. Clin. North America, vol. No. 3, June, 1921. 

4 Arch. Ped., vol. xxxvi. No. 7, 1919. 

5 Jour. Amer. Med. Assoc, July 24, 1920. 



464 PRACTICAL INFANT FEEDING 

should be resorted to. Rapid loss of weight is the most important 
point in favor of operation, and if progress down hill is steady 
and rapid, operation must not be delayed, as it is of the utmost 
importance to do it before the baby is in very bad nutritional 
condition. 

Medical treatment may be discussed under three headings: 
feeding, stomach washing, and drugs, of which the first is the 
most important. 

Feeding. — In either type of case, whether spasm or stenosis, 
it is worth while to try feeding with breast milk, provided the 
baby is not already on the breast. If he is already on the breast 
and vomits, or if breast milk is unobtainable, the thick cereal 
feeding, first advocated by Sauer,^ is the most successful method. 

His original formula was as follows: 

Skimmed milk 9 ounces; 

Water 12 ounces; 

Farina 6 tablespoonfuls; 

Dextrimaltose. 3 tablespoonfuls 

This is boiled one hour in a covered double boiler, and con- 
tains about 15 per cent, of cereal. It must be of a thick con- 
sistency, so that it will barely run off a spoon. From 2 to 8 
tablespoonfuls, according to the size of the baby, are given 
every three hours. 

Since Sauer's original paper it has been found that some- 
what thinner mixtures work better, and the amount of farina 
now ordinarily employed is 1 tablespoonful to 5 ounces of liquid. 

Porter^ recommends using rice flour in the proportion of 
1 tablespoonful to 7 ounces of liquid, and believes that this 
works better than farina, especially if farina causes a tendency 
to diarrhea, which it may do occasionally. 

The mixture is so thick that it cannot ordinarily be taken 
from a bottle. It is usually given on the end of a throat stick, 
then the cereal is pushed into the back of the mouth wdth another 
throat stick. Or, as Dr. Griffith, of Philadelphia, suggests,^ it 

1 Arch. Ped., July, 1918. 2 Trans. Amer. Ped. Soc., 1921. 

3 Ibid. 



PYLORIC STENOSIS AND SPASM 465 

may be given through a large-holed Hygiea nipple by pushing it 
through with a spoon, while the nipple is in the baby's mouth. 

It is not necessary to adhere strictly to any set formula in 
using the thick cereal principle; it is merely necessary to use 
small amounts of a concentrated, rather thick mixture, con- 
taining large amounts of starch, which is so thick and adhesive 
that it is vomited with difficulty. Whole or skimmed milk may 
be used in various proportions, according to the exigencies of 
the case, and sugar may or may not be added. 

It must be remembered that these mixtures contain a large 
amount of starch, and that although the vomiting may stop, 
an intestinal indigestion due to excess of starch may arise. It 
is well, therefore, to examine the stools for starch under the 
microscope occasionally, and to cut down the amount fed if 
much undigested starch is coming through. It is always neces- 
sary to give water between feedings in order to cover the baby's 
fluid needs. 

This is probably the most successful method of feeding this 
group of cases, and good results have been reported by almost 
all those who have used it. Personally, I have had compara- 
tively little experience with it, but have secured good results in 
the few cases where it has been used. 

Another way of feeding, especially in pylorospasm, is with 
dried milk containing a low fat (Dryco). This often works sur- 
prisingly well. It is usually best to begin with one-half strength, 
4 level tablespoonfuls of dried milk to 8 ounces of water, and to 
gradually increase until full or nearly full strength is reached. 
Occasionally it is advantageous to combine a barley or farina 
gruel (about 3 per cent.) with the dried milk mixture. 

Whey is often of value as a temporary food, and mixtures 
of gravity cream and whey have long been used. These are, 
as a rule, not very satisfactory, as in order to supply sufficient 
caloric value for weight increase it is necessary to use a fairly 
high fat percentage which is directly contraindicated in feeding 
any baby with an irritable stomach. 

Stomach washing may sometimes be of value. A 1 per cent. 
30 



466 PRACTICAL INFANT FEEDING 

solution of sodium bicarbonate at blood heat is used. The wash- 
ing is best done about one-half hour before feeding once or twice 
a day. 

Stomach washing has the great disadvatage that it disturbs 
the baby a good deal. It is worth a trial, however. 

Atropin. — Inasmuch as the pathologic condition in pyloro- 
spasm consists of a spasm of smooth muscle, and as most cases 
of pyloric stenosis are complicated by spasm, the administration 
of atropin would seem to be theoretically indicated. This has 
been used for a long time, with not very enthusiastic reports, 
until that of Haas^ in 1919, who believes that excellent results 
can be secured with larger doses without danger to the baby. 
He reconunends a 1 : 1000 solution of atropin sulphate, con- 
taining about T^^ grain to the drop. A drop of this is put 
into each feeding, or is given in water if the baby is breast fed. 
If this is well borne, 2 drops are used at the next feeding, and so 
on, until at the end of twenty-four hours the dose may be 3 or 
4 drops with each feeding. If the dosage used does not produce 
beneficial results, and if there are no symptoms of atropin- 
poisoning, the dose is increased to 5 or 6 drops with each feeding. 
It may be necessary to keep up the treatment for several weeks 
or even months. 

Atropin treatment should always be tried. I have myself, 
however, never seen any very striking results from it. 

Prognosis.— Most cases of pylorospasm recover with careful 
medical treatment. It is, however, a most annoying condition, 
and progress is likely to be slow. The institution of thick cereal 
feeding has done more to help us than anything else. ^ 

Not a few cases of mild pyloric stenosis likewise recover 
under medical treatment. There is always the suspicion that 
these may be cases of spasm and not of true pyloric stenosis. 
If after ten days or so of medical treatment loss of weight con- 
tinues, and the vomiting is no better, operation should be 
resorted to at once. 

1 Arch. Ped., vol. Z6, 1919. 



INDEX 



Abnormal breast-fed baby, 116 
Abscess of breast, 112 
Absorption of ash, 59 

of calcium, 59, 60 
effect of increasing amounts of 
fat on, 61 

of chlorids, 65 

of fat, 39 

of iron, 64 

of phosphorus, 63 

of potassium, 62 

of protein, 37 

of sodium, 62 

of starch, 56 

of sugar, 48 

of sulphur, 64 
Accessory food factors, 65^ 
Acid, hydrochloric, free, in stomach, 
24 

in fat of cow's milk, 147 

lactic, organisms in cow's milk, 150 

stools, 78 
Albumin milk, 215 
Alimentary intoxication, 139, 299 
Alkalies for normal artificially fed 
infant, 239 

used in special preparations, 212 
Alkaline secretion of duodenum, 25 

stools, 79 
American Association of Medical 

Milk Commissions, 158 
Amylopsin, 27 
Anaphylactic food tests in eczema, 

449 
Antiscorbutic foods in scurvy, 436 

vitamin, water-soluble C, 68 
Appetite, habitual loss of, 360 
causes, 360 

loss_ of, in children from one to 
eight years old due to poor daily 
routine, 363 

poor, in children from four to eight 
years of age, 365 
tonic for, 366 
Aprotein, 219 



Artificial feeding, modern, develop- 
ment of, 124 
Biedert, Meigs, and Rotch 

in, 125 
Czerny and Keller's work in, 

134 ^ 
Escherich's work in, 133 
fat period in, 134 
Finkelstein's work in, 137 
in America, 128 
influence of Biedert, 128 
Meigs' work in, 128 
protein period in, 125 
retrospect of Biedert, Meigs, 

and Rotch, 131 
Rotch's work in, 129 
Widerhofer's work in, 132 
of normal infant, 228 
alkalies for, 239 
amount at each feeding, 237 
of fat for, 238 
of protein for, 239 
of starch for, 239 
of sugar for, 238 
amounts of food elements to 

use, 238 
caloric method, 229 
general plan, 230 
green vegetables, 234 
interval for, 238 
newborn period, 231 
nine months to one year, 233 
orange juice in, 243 
second period, 232 
solid food, 234 
third period, 233 
three weeks to nine months, 

232 
water for, 243 

whole milk mixtures from 
start, 233 
Artificially fed infant, acute fat in- 
digestion in, 258 
treatment, 258_ 
protein indigestion in, 263 
467 



468 



INDEX 



Artificially fed infant, acute protein in- 
digestion in, treatment, 264 
starch indigestion in, 264 
sugar indigestion in, 259 
^ treatment, 261, 262 
chronic fat indigestion in, 265 
with constipated stools, 

268 
with loose stools, 272 
sugar indigestion in, 274 
treatment, 274 
digestive and nutritional dis- 
turbances in, 252 
energy quotient in, 74 
intestinal flora in, 31 
underfeeding in, 256 
normal infant, gain in weight in, 
240 
general condition, 244 
stools of, 242 
urine of, 243 
Ash, absorption of, 59 

content of colostrum, 18, 90 

of human milk, 90 
in cow's milk, 59 
in human milk, 59 
Assimilation limits of different sugars, 

49 
Athrepsia, 139, 275 
Atrophy, infantile, 139, 275 ^ 
Atropin in pyloric stenosis with slight 
obstruction, 466 



Babies fed on condensed milk, types 

of, 233 
Bacillus, gas, test for, in stools, 88 

lactic acid, inoculating milk with, 
213 
Bacteria in cow's milk causing ab- 
normal conditions in milk, 151 

intestinal, 28 

kinds, 31 

protein-splitting, 151 

relation of, to food, 28 

spore-bearing, in cow's milk, 151 

types of, dependence of, on food 
supply, 32 

which produce fermentation, types 
of, 34 
putrefaction, types of, 34 
Bacteriology of cow's milk, 149 

of digestive tract, 28 

of human milk, 98 

of large intestine, 31 

of small intestine, 30 

of stomach, 29 
Barley jelly, 211 

malt, 205 



Barley-water, 210 
Basal energy requirement, 69 
Bathing in eczema, 446 
Beef juice, 222, 248 
Biedert, influence of, in development 
of modern artificial feeding, 128 
Meigs, and Rotch in development of 
modern artificial feeding, 125 
Biedert 's cream conserve, 126 
Bilanzstorung, 40, 268 
Bile, 27 
color of, 27 
function of, 27 
in stools, test for, 89 
Bismuth in fermentative diarrhea, 308 
in infectious diarrhea, 317 
ointment for dry, rough, not 
acutely inflamed, eczema, 441 
Bitter milk, 152 
Blood in urine in scurvv, 427 
Blue milk, 151 

Body temperature of newborn, 19 
Boiled milk, advantages of, 173 
disadvantages of, 173 
versus pasteurized milk, 175 
Boiling of milk, 171 

changes produced by, 171 
Bones in rickets, Roentgen-ray appear- 
ance of, 387 
long, in rickets, 383 
Borcherdt's drimalt soup extract, 
composition of, 207 
dry malt soup extract with wheat 

flour, composition of, 208 
malt soup extract, composition of, 
207 
sugar, 206 

composition of, 207 
Boric ointment in seborrheic eczema, 

442 
Bottle fed. See Artificially fed infant. 
Bow-legs in rickets, 386 
Brandy, 308 
Breast, abscess of, 112 
caking of, 112 
fed, fecal flora of, 31 
feeding, 100 

amount at each feeding, 109 

at night, 109 

contraindications to, 115 

during menstruation, 114 

importance of, 100 

in first few days, 104 

in pregnancy, 114 

intervals of nursing, 105, 108 

overfeeding in, 121 

substituting one bottle feeding, 

109 
three-hour interval in, 105, 108 



INDEX 



469 



Breast feeding, underfeeding in, 118 
vomiting in, 116 
milk, average amounts taken in 
first ten days, 23 
in spasmophilia, 414 
Breast-fed infant, energy quotient in, 
70 
fecal flora of, 31 
intestinal flora in, 31 
normal, average weights at differ- 
ent ages, 240 
overfeeding of, 121 
stools of, 110 
underfeeding of, 118 
weaning of, 110 
Breath holding, 411 
Breck feeder for premature infants, 

352 ^ 
Bronchial tetany in spasmophilia, 409 
Butter fat, use of other fats in place 

of, 201 
Buttermilk and water with dried 
casein, 218 
composition of, 214 
Buttocks, excoriated, applications for, 
308 



Caffein, 308 
Caking of breast, 112 
Calcium, absorption of, 59, 60 

effect of increasing amounts of 
fat on, 61 
and sodium interrelationship in 

spasmophilia, 405 
in cow's milk, 59 
in human milk, 59, 97 
in rickets, 398 
in spasmophilia, 415^ 
lack of, as cause of rickets, 374 
metabolism in etiology of spas- 
mophilia, 404 
Caloric method of artificial feeding, 
229 
requirements of infants, 69 

of normal babies and children, 
tables of, 72, 73 
children of different ages, table 
showing, 329 
value of human milk, 96 
Calorie, 69 

Calories in modified milk feeding, 194 
Cane-sugar, 204 

Carbohydrate, metabolism of, 45 
Care of nipples, 104 
Carpopedal spasm in spasmophilia, 
408 
treatment, 413 
Casafru in constipation, 358 



Casec, 219 
milk, 259 
Casein, coagulation of, mechanism of, 

37 
curds, 263 

in protein stools, 87 
dried, plus whole milk or butter- 
milk and water, 218 
in cow's milk, 148 
in emptying time of stomach, 25 
in human milk, 96 
Castor oil in constipation, 358 
Celiac disease, 321 
Cells in cow's milk, 149 
Cereal diluents, 210 
Certified milk, 157 

standards for, 158 
Chalk, precipitated, in fermentative 

diarrhea, 307 
Children, normal, of different ages, 
caloric requirements of, table 
showing, 329 
older, chronic intestinal indigestion 
in, 321 
weights of, 241 
Chloral in spasmophilia, 412 
Chlorids, absorption of, 65 
in cow's milk, 65 
in human milk, 65, 97 
Chloroform in spasmophilia, 412 
Chondrodystrophy fcetalis, 394 
Chvostek's sign in spasmophilia, 406 
Circulatory system in scurvy, 429 
Citric acid content of human milk, 

97 
Classification and nomenclature in 
infant feeding, 254 
etiologic, of disorders of infant 
feeding, 255 
Coagulation of casein, mechanism of, 

37 
Coal-tar, crude. In wet, oozing eczema, 

439, 440 
Cod-liver oil, 246 
in rickets, 397 
in spasmophilia, 416 
Collapse in infectious diarrhea, treat- 
ment, 318 
Colonic irrigations in fermentative 
diarrhea, 304 
in infectious dysentery, 316 
Color of bile, 27 

of normal infant, 245 
of stools in infancy, 27, 77 
Colostrum, 18, 90 
amount of, 18, 90 
ash content of, 90 
composition of, 90 
contents of, 18 



470 



INDEX 



Colostrum corpuscles, 91 

period, 18 
Complemental feeding, 119 
Condensed milk, 222 
composition of, 223 
types of babies fed on, 223 
Congenital hypertrophic stenosis of 

pylorus, 452 
Conserve, cream, Biedert's, 126 
Constipation in infancy, 356 
drugs in, 358 
enemata in, 358 
food in, 357 

milk of magnesia for, 242 
suppositories in, 358 
treatment, 357 
Contraindications to nursing, 115 
Convulsions, general, in spasmophilia, 

409 
Cooking of milk, 170 
Corn syrup and lactic acid milk mix- 
tures, 209 
composition of, 209 
Corpuscles, colostrum, 91 
Cow, garget in, 154 
mastitis in, 154 
tuberculosis in, 154 
tuberculin test for, 155 
Cow's milk and human milk, essential 
differences between, 176 
ash in, 59 
bacteria in, _ causing abnormal 

conditions in, 151 
bacteriology of, 149 
calcium in, 59 
casein in, 148 
cells in, 149 
chlorids in, 65 
fat in, 146 

acids in, 147 
ferments in, 149 
idiosyncrasy to, 289 
desensitization, 292 
diagnosis, 290 
treatment, 291 
iron in, 63 
lactalbumin in, 148 
lactic acid organisms in, 150 
lactose in, 148 
magnesium in, 59 
phosphorus in, 63 
potassium in, 62 
protein in, 148 
salt content of, 55, 148 
saprophytic organisms in, 150 
sodium in, 62 

spore-bearing bacteria in, 151 
streptococci in, 153 
sulphur in, 64 



Cracked nipples, 111 
Cradle cap, 442 
Cream conserve, Biedert's, 126 
dilutions, 186 

gravity and skimmed milk mixtures, 
188 
long method of calculation, 

197 
principles of calculation, 

191 
short method of calcula- 
tion, 190 
Crying, 244 

Curdling of milk by rennin, 211 
Curds, casein, 263 

Czerny and Keller's classification of 
nutritional disturbances, 134 
work in development of modem 
artificial feeding, 134 
Czerny's milk modification, 136 

Dairy, hygiene of, 158 

Decomposition, 139, 275 

Deformity, prevention of, in rickets, 

399 
Dehydration, prevention of, in fer- 
mentative diarrhea, 304 
Depressed nipples, 111 
Development of modern artificial 

feeding, 124 
Dextrimaltose, Meade's, 206 

composition of, 207 
Dextrose, 209 
Diarrhea, 27, 293 
fat, 81 

absorption in, 40 
fermentative, 260, 294, 296 

bismuth in, 308 

colonic irrigations in, 304 

constitutional weakness in, 297 

dehydration in, 304 

drugs in, 307 

electric fan in, 308 

excoriated buttocks In, 308 

gas bacillus test in, 313 

infected milk in, 297 

intraperitoneal saline injection in, 
306 

intravenous injections In, 307 

medicinal treatment, 304 

opium in, 307 

overfeeding with sugar In, 296 

overheating of body in, 297 

parenteral infections in, 297 

precipitated chalk in, 307 

protein form of, 309 

stimulants in, 308 

subcutaneous saline injections in, 
305 



INDEX 



471 



Diarrhea, fermentative, sugar fermen- 
tation in, 298 
treatment, medicinal, 304 
of mild cases, 300 
of severe cases, 300 
water in, 304 
from sugar, 43 
infectious, 309 
bismuth in, 317 
collapse in, treatment, 318 
diagnosis, 312 
drugs in, 317 
feeding in, 315 

hyperpyrexia in treatment, 318 
intussusception and, differentia- 
tion, 312 
nervous symptoms in, treatment, 

318 ^ 
opium in, 317 
prognosis, 318 
symptoms, 310 
tannalbin in, 317 
treatment, 313 

of special symptoms, 318 
vomiting in, treatment, 318 
mechanical, 294, 295 
stools of, 77 
summer, 293 
Diarrheal diseases, 293 
groups of, 294 
prophylaxis of, 319 
Diastoid, Horlick's, composition of, 

207 
Diet at fourteen months, 249 
during second year, 246 
from sixteen months to two years, 

250 
from two to three years, 250 
in moderately severe starch Indi- 
gestion for baby of 2| years 
weighing 20 pounds, 335 
in severe combined starch and fat 
indigestion, 335 
fat indigestion for baby of 2| years 
weighing 18 pounds, 333 
of nursing mother, 103 
Diffuse papular eczema, 444 
. Digestion in intestines, 26 
in mouth, 22 
in stomach, 24 
of protein, 37 
of sugar, 48 
pancreatic, 27 
pathology of, 17 
physiology of, 17 
Digestive and nutritional disturb- 
ances in bottle fed, 252 
tract, bacteriology of, 28 
in scurvy, 429 



Digestive tract, physiology of, 22j 
Diluent, cereal, 210 
Disaccharids in infant feeding, 204 
Disease, acute, in nursing mother, 113 
Diseases transmitted by milk, 156 
Disturbed balance, 138 
Dried casein plus whole milk or butter- 
milk with water, 218 
Drimalt soup extract, Borcherdt's, 

composition of, 207 
Drugs in constipation in infancy, 358 

in fermentative diarrhea, 307 

in human milk, 98 

in infectious diarrhea, 317 

in rickets, 397 

in spasmophilia, 415 " 
Dry milk powders, 219 
Dryco, 219 

brand of dried milk, composition of, 
219 
Duodenum, secretion of, 25 
Dysentery, feeding in, 314, 315 

infectious, colonic irrigations in, 
316 ^ 

purgation in, 314 

starvation in, 315 

treatment in, 314 
Dyspepsia, 139, 260 



Eczema in infancy, anaphylactic food 
tests in, 449 
bathing in, 446 

diffuse papular or vesicular, 444 
dry red, acutely inflamed, 441 
rough, not acutely inflamed, 
441 
etiology, 438 
feeding in, 447 
idiosyncrasy to food proteins in, 

449 
infected, 444 
intertriginous, 443 

whitewash for, 443^ 
prevention of scratching, 445 
seborrheic, 442 
treatment, 438 
local, 438 

ten preparations for, 445 
types, 438 
wet, oozing, 439 

crude coal-tar for, 439, 440 
Egg and potato, 249 
Eiweiss milk, 54, 140, 215 
Eiweissmilch, 54, 140, 215 

purpose of, 54 
Electric fan in diarrheal diseases, 308 
irritability in spasmophilia, 407 
reactions in spasmophilia, 416 



472 



INDEX 



Emptying time of stomach, 24 
Enema, soapsuds, for constipation, 242 

for gas, 244 
Enemata, 358 
Energy quotient, 70 

in breast-fed babies, 70 

requirement, basal, 69 
of infants, 69 
Enterokinase, 26 
Epinephrin, 308 
Epiphyses at knee and ankles in 

rickets, 387 
Epiphysitis, syphilitic, scurvy and, 

differentiation, 430 
Erb's phenomenon in spasmophilia, 

407 
Erepsin, 26 
Escherich's work in development of 

modern artificial feeding, 133 
Ester, 147 

Ether in spasmophilia, 412 
Etiologic classification of disorders of 

infant feeding, 255 
Evaporated milk, 224 
Excoriated buttocks, applications for, 

308 
Exophthalmos in scurvy, 428 
Exsiccation fever, 21 
Extremities in rickets, 385 

Facial phenomenon In spasmophilia, 

406 
Fat, absorption of, 39 

and starch indigestion, severe, com- 
bined, diet for, 335 
butter, 147 

use of other fats in place of, 201 
content of colostrum, 18 
of stools, groups of, 83 
diarrhea, 81 
in cow's milk, 146 

acids in, 147 
in stools, 80 

in older children, 84 
macroscopic examination, 80 
of normal and abnormal bottle- 
fed babies, 44 
breast- and bottle-fed babies, 
44 
increasing amounts of, effect on 

calcium absorption, 61 
indigestion, acute, in bottle fed, 258 
treatment, 258 
chronic, 40, 61 
in bottle-fed, 265 

with constipated stools, 268 
with loose stools, 272 
severe, diet for baby 2| years old 
weighing 18 pounds, 333 



Fat Injury, 135 

intake, percentage absorbed, 39 
metabolism of, 38 

mixtures, synthetic, prepared to 
resemble fat of human milk, 203 
of human milk, 95 

and of cow's milk, differences 

between, 176 
synthetic fat mixtures pre- 
pared to resemble, 203 
of milk, effect of boiling on, 172 
partition in stools, 42 
period in development of modern 
artificial feeding, 134 
Fat-soluble A, 65, 66 
action of, 66 

as cause of rickets, 375-377 
Fats used in place of butter fat, 201 
Fecal flora of breast fed, 31 
Feeding, artificial, 124. See also 
A rtificial feeding. 
at fourteen months, 249 
breast, 100. See also Breast feeding. 
complemental, 119 
difficult, general suggestions for 

cases of, 286 
during second year, 246 
from sixteen months to two years, 

250 
from two to three years, 250 
supplemental, 120 
Fermentation, 32 
of sugar, 50 

chemistry of, 50 

conditions which bring about, 52 

degrees of, 298 

feeding in, 301 

FInkelstein's treatment of, 140 

lactic acid milk in, 303 

protein milk in, 301 

purgation in, 300 

simple skimmed milk dilutions 

In, 304 
skimmed milk with powdered 

casein In, 302 
treatment in mild cases, 300 
In severe cases, 300 
types of bacteria which produce, 
34 
Fermentative diarrhea, 260, 296. See 

also Diarrhea, fermentative. 
Fermented starch stools, 85 
Ferments In cow's milk, 149 

In milk, effect of boiling on, 172 
Fetal rickets, 367 
Fettnahrschaden, 135 
Fever, exsiccation, 21 
inanition, 20 
transitory, of newborn, 20 



INDEX 



473 



Fever, transitory, of newborn, diag- 
nosis, 21 
etiology, 21 
treatment, 22 
Finkelstein's classification of nutri- 
tional disturbances, 138 
milk, 140 

treatment of sugar fermentation, 140 
work in development of modern 
artificial feeding, 137 
Fissures of nipples, 112 
Food, changes in, variation in milk 
elements from, 98 
elements, metabolism of, 34 
Horlick's, composition of, 207 
Mellin's, composition of, 207 
proprietary, 225 

proteins, idiosyncrasy to, in ec- 
zema, 449 
relation of bacteria to, 28 
supply, dependence of type of 

bacteria on, 32 
tests, anaphylactic, in eczema, 449 
values, table of, 328 
Formaldehyd in milk, Hehner's test 

for, 156 
Formalin as preservative of milk, 156 
Fragilitas ossium, 395 
Fredet-Rammstedt operation in py- 
loric stenosis and spasm, 461 
Frozen milk, 157 

Gain in weight in normal artificially 

fed infant, 240 
Galactogogues, 93 
Garget in cow, 154 
Gas bacillus, test for, in stools, 88 
technic of, 313 
soapsuds enema for, 244 
Gastro-intestinal tract, bacteriology 

of, 28 
General suggestions for difficult feed- 
ing cases, 286 
Goat's milk, 220 

composition of, 221 
evaporated, 221 
Grape sugar, 204 

Gravity cream and skimmed milk 
mixtures, 188 
long method of calculation, 

197 
principles of calculation, 

191 
short method of calcula- 
tion, 190 
Green vegetables, 248 

in artificial feeding of normal 
Infants, 243 
Gums in scurvy, 427 



Habitual loss of appetite, 360 
Harrison's groove in rickets, 383 
Hehner's test for formaldehyd in 

milk, 156 ^ 
Hemorrhage into skin in scurvy, 427 
High protein stools, 86 
Holt and Fales' tables of caloric 
requirements for normal babies and 
children, 72, 73 
Homogenization of milk, 201 
Homogenized olive oil in place of 

butter fat, 202 
Horlick's diastoid, composition of, 207 

food, composition of, 207 
Human milk, 90 
amount of, 92 
ash content of, 59, 90 
bacteriology of, 98 
biologic substances of, 97 
calcium in, 59 

content of, 97 
caloric value of, 96 
casein of, 96 

chemical composition of, 94 
chlorids in, 65, 97 
citric acid content of, 97 
color, 91 
coming in of, 91 
drugs in, 98 
fat of, 95 

synthetic fat mixtures pre- 
pared to resemble, 203 
galactogogues for, 93 
iron in, 63, 97 
lactalbumin of, 96 
lactoglobulin of, 96 
magnesium in, 59 
non-protein nitrogenous consti- 
tuents of, 96 
phosphorus in, 63 
physical properties of, 91 
potassium in, 62 
protein of, 95 
salt content of, 55 
salts of, 97 
sodium in, 62 
specific gravity, 91 
sugar in, 95 
sulphur in, 64 
taste, 91 ^ 

variations in, through changes in 
food, 98 ^ 
Hydrobilirubin in stools in infancy, 

78 
Hydrochloric acid, free, in stomach, 

antiseptic power of, 24 
Hygiene of dairy, 158 
Hyperpyrexia in infectious diarrhea, 
treatment, 318 



474 



INDEX 



Idiosyncrasy to cow's milk, 289 
desensitization, 292 
diagnosis, 290 
treatment, 291 
to food proteins in eczema, 449 
Inanition fever, 20 

Indigestion, fat, acute, in bottle fed, 
258 
treatment, 258 
chronic, 40, 61 
in bottle fed, 265 

with constipated stools, 268 
with loose stools, 272 
severe, diet for baby 2| years old 
weighing 18 pounds, 333 
intestinal, chronic, 276 

in older children, 321 
protein, acute, in bottle fed, 263 

treatment, 264 
starch, acute, in bottle fed, 264 
moderately severe, diet for baby 
of 2| years weighing 20 pounds, 
335 
omitting all starch in, 334 
sugar, 260 

chronic, in bottle fed, 274 

treatment, 274 
in bottle fed, 259 
treatment, 261 
Infancy, constipation in, 356, See also 
Constipation in infancy. 
eczema in, 438. See also Eczema in 

infancy. 
stools in, 75. See also Stools in 
infancy. 
Infant, energy requirements of, 69 
feeding, classification and nomen- 
clature in, 254 
special preparations used in, 201 
newborn, average weight of, 17 
birth weight of, regaining, 19 
body temperature of, 19 
gain in weight of, 106 
loss of weight of, 17, 106 
amount, 18, 19 
duration, 18 
prevention of, 19 
sepsis in, 21 
transitory fever of, 20 
vomiting in, 116 
cause, 117 
normal, artificial feeding of, 228. 

See also Artificial feeding. 
premature, 340. See also Premature 
infants. 
Infantile atrophy, 139, 275. 
scurvy, 419. See Scurvy. 
Infantilism, intestinal, 276, 321 
Infected eczema, 444 



Infected milk in fermentative diar- 
rhea, 297 
Infection, nutritional disturbances 
from, 136 
parenteral, in fermentative diarrhea, 
297 
Infectious diarrhea, 309. See also 

Diarrhea, infectious. 
Injections, intraperitoneal saline, in 
fermentative diarrhea, 306 
intravenous, in fermentative di- 
arrhea, 307 
subcutaneous saline, in fermentative 
diarrhea, 305 
Intertriginous eczema in infancy, 443 

whitewash for, 443 
Intestinal bacteria, 28 
indigestion, chronic, 276 
in older children, 321 

articles of food used in, 329 
cottage cheese in, 331 
course, 337 
definition, 321 
diagnosis, 325 
eggs in, 331 
etiology, 321 
fat in, 330 
fruit in, ZZZ 
protein in, 330 
prognosis in, 337 
milder cases, 338 
milk, in 329 
starch in, 330 
sugar in, 2>dt 1 
symptoms, 323 
treatment, 325, 336^ 
tubercular peritonitis and, 

differentiation, 326 
vegetables in, 332 
infantilism, 276, 321 
Intestines, 26 

action of protein in, 37 
digestion in, 26 
large, bacteriology of, 31 
small, bacteriology of, 30 

secretion of, 26 
sugar in normal action of, 49 
Intoxication, 139 

alimentary, 139, 299 
Intraperitoneal saline injection in 

fermentative diarrhea, 306 
Intravenous injections in fermentative 

diarrhea, 307 
Intussusception, infectious diarrhea 

and, differentiation, 312 
Invertase, 26 
Inverted nipples, 111 
Invertin, 26 
Iron, 57 



INDEX 



475 



Iron, absorption of, 64 
in cow's milk, 63 
in human milk, 63, 97 
in rickets, 398 



Jaws and teeth in rickets, 382 
Jelly, barley, 211 

oat, 211 
Juice, beef, 222, 248 

lemon, 437 

lime, 437 

orange, 235, 243, 437 

tomato, 437 



Keller and Czerny's work in develop- 
ment of modern artificial feeding, 
134 

Keller's malt soup, 207 

Klim dried milk, composition of, 219 

Knock-knee in rickets, 386 

Kyphosis in rickets, 387 



Lactalbumin in cow's milk, 148 

of human milk, 96 
Lactation, difficulties arising during, 

111 
Lactic acid bacilli, inoculating milk 
with, 213 
milk, 213 
and corn syrup mixtures, 209 
in sugar fermentation, 303 
organisms in cow's milk, 150 
Lactoglobulin of human milk, 96 
Lactose, 50 

content of colostrum, 18 
in cow's milk, 148 
in infant feeding, 204 
Large intestine, bacteriology of, 31 
Larosan, 218, 259 

Laryngeal stridor, congenital, laryn- 
gismus stridulus and, differentia- 
tion, 411 
Laryngismus stridulus, congenital lar- 
yngeal stridor and, diflferentia- 
ation, 411 
in spasmophilia, 408 
^ treatment, 413 
Legs in scurvy, 426 
Lemon juice, 437 
Lime juice, 437 
Lime-water, 212 
Liver, 27 

function of, 27 
Long bones in rickets, 383 
Loss of water from body, 18 



Macroscopic examination of stools, 

80 _ 
Magnesia, milk of, in constipation, 

358 
Magnesium in cow's milk, 59, 62 

in human milk, 59, 62 
Malnutrition, Marriott's method of 

feeding in, 209 
Malt soup extract, Borcherdt's, com- 
position of, 207 
dry, Borcherdt's, with wheat 
flour, composition of the, 
208 
Meade's, with wheat flour, 
composition of, 208 
Maltine, composition of, 207 
Keller's, 207 
sugar, 204 

Borcherdt's, 206 

composition of, 207^ 
preparations, composition of, 207 
Maltase, 26 
Maltine malt soup, 206 

extract, composition of, 207 
Maltose in infant feeding, 204 
Maltose-dextrin preparations, 204 
contraindications for, 206 
indications for, 206 
Marasmus, 139, 256, 275 
artificial feeding in, 280 
clinical appearance, 278 

history, 277 
course, 284 
definition, 275 
drugs in, 284 

etiology and pathogenesis, 276 
injections in, 284 
occurrence, 276 
prognosis, 286 
treatment, 279 
warmth in, 283 
Marriott's method in malnutrition, 

209 
Mastitis, 112 
in cow, 154 
milk, 154 
Meade's dextrimaltose, 206 
composition of, 207 
dry malt-soup extract with wheat 
flour, composition of, 208 
Mechanical diarrhea, 294. See also 
Diarrhea, mechanical. 
loss of weight in newborn, 17 
Meconium, 106 

Medical Milk Commission, 158 
Mehlnahrschaden, 135 
Meigs, Biedert, and Rotch in develop- 
ment of modern artificial feeding, 
125 



476 



INDEX 



Meigs' work in development of modern 

artificial feeding, 128 
Mellin's food, 206 

composition of, 207 
Menstruation, breast feeding during, 

114 
Metabolism of carbohydrate, 45 
of fat, 38 

of food elements, 34 
of mineral salts, 56 
of protein, 34 
Microscopic examination of stools, 81 
first procedure, 82 
for starch, technic, 86 
second procedure, 82 
Milchnahrschaden, 48 
Milk, albumin, 215 
at summer resorts, 175 
bitter, 152 
boiled, advantages of, 173 

disadvantages of, 173 
boiling of, 171 

changes produced by, 171 
breast, in spasmophilia, 414 
blue, 151 
casec, 259 
certified, 158 

standards for, 158 
condensed, 222 

composition of, 223 
types of babies fed on, 223 
cooking of, 170 
cow's, ash in, 59 

average composition, 145 
bacteria in, causing abnormal 

conditions in, 151 
bacteriology of, 149 
calcium in, 59 
casein in, 148 
cells in, 149 
chlorids in, 65 
fat in, 146 

acids in, 147 
ferments in, 149 
idiosyncrasy to, 289 
desensitization, 292 
diagnosis, 290 
treatment, 291 
iron in, 63 
lactalbumin in, 148 
lactic acid organisms in, 150 
lactose in, 148 
magnesium in, 59 
phosphorus in, 63 
potassium in, 62 
protein in, 148 
salt content of, 55, 148 
saprophytic organisms in, 150 
sodium in, 62 



Milk, cow*s, spore-bearing bacteria in, 
151 

streptococci in, 153 

sulphur in, 64 
curdling of, by rennin, 211 
diseases transmitted by, 156 
dried, 219 
eiweiss, 140 
evaporated, 224 
Finkelstein's, 140 
formaldehyd in, Hehner's test for, 

156 
frozen, 157 
goat's, 220 

composition of, 221 

evaporated, 221 
homogenization of, 201 
human, 90 

amount of, 92 

and cow's milk, differences be- 
tween, 176 

ash content of, 59, 90 

bacteriology of, 98 

biologic substances of, 97 

calcium content of, 59, 97 

caloric value of, 96 

casein of, 96 

chemical composition of, 94 

chlorids in, 65, 97 

citric acid content of, 97 

color, 91 

coming in of, 91 

drugs in, 98 

fat of, 95 

synthetic fat mixtures pre- 
pared to resemble, 203 

galactogogues for, 93 

iron in, 63, 97 

lactalbumin of, 96 

lactoglobulin of, 96 

magnesium in, 59 

non-protein nitrogenous constit- 
uents of, 96 

phosphorus in, 63 

physical properties of, 91 

potassium in, 62 

protein of, 95 

salt content of, 55, 97 

sodium in, 62 

specific gravity, 91 

sugar of,^ 95 

sulphur in, 64 

taste, 91 

variations in, through changes in 
food, 98 
infected, in fermentative diarrhea, 

297 
inoculating with lactic acid bacilli, 

213 



INDEX 



477 



Milk, lactic acid, 213 

and corn syrup mixtures, 209 
in sugar fermentation, 303 
magnesium in, 62 
mastitis, 154 
modification of, 180 
Czerny's formula, 136 
gravity cream and skimmed milk 

mixtures, 188 
methods of, 181 
top milk (cream) dilutions, 186 
whole milk dilutions, 181 
modified, calories in formula, 194 
molds in, 152 

of magnesia for constipation, 242, 358 
pasteurization of, 170 

what it accomplishes, 170 
peptonization of, 212 
preservatives in, 156 
protein, 55, 140, 215 
dried, 218 

preparation of, 216 
in sugar fermentation, 301 
salt content of, 55 
red, 151 

skimmed, and gravity cream mix- 
tures, 188 
long method of calculation, 

197 
principles of calculation, 

191 
short method of calculat- 
ing, 190 
dilutions in sugar fermentation, 
304 
with dried casein, 218^ 
with powdered casein in sugar 
fermentation, 302 
slimy and stringy, 151 
sour, chemical changes in, 153 
souring of, 152 

taste of, effect of boiling on, 172 
top (cream), dilutions, 186 
whole, dilutions, 181 

with dried casein, 218 
yeasts in, 152 
Milk-sugar, 204 
Milking, directions for, 105 
Mineral salts, metabolism of, 56 
Modification of milk, 180. See also 

Milk, modification of. 
Molds in milk, 152 

Monosaccharids in infant feeding, 204 
Morphin in spasmophilia, 413 
Mother, nursing, 102 
acute disease in, 113 
diet of, 103 
Motility of stomach, 24 
Mouth, digestion in, 22 



Nephritis, acute, scurvy and, differ- 
entiation, 431 
Nervous symptoms in infectious diar- 
rhea, treatment, 318 
Newborn, average weight of, 17 
birth weight of, regaining, 19 
body temperature of, 19 
gain in weight of, 106 
loss of weight of, 17, 106 
amount, 18, 19 
duration, 18 
prevention of, 19 
sepsis in, 21 
transitory fever of, 20 
diagnosis, 21 
etiology, 21 
treatment, 22 
vomiting in, 116 
cause, 117 
Nipples, care of, 104 
cracked. 111 
depressed. 111 
fissures of, 112 
inverted. 111 
Nitrogen and salts retention, relation 

of sugar to, 46 
Nomenclature and classification in 

infant feeding, 254 
Non-protein nitrogenous constituents 

of human milk, 96 
Non- volatile acids, 51 
in butter fat, 147 
Normal appearing stool, 81 

infant, artificial feeding of, 228. 
See also Artificial feeding. 
average weight of, 17 
Nursing mother, 102 

acute disease in, 113 
diet of, 103 
Nutrition, pathology of, 17 

physiology of, 17 
Nutritional and digestive disturbances 
in bottle fed, 252 
disturbances, Czerny and Keller's 
classification of, 134 
Finkelstein's classification, 138 
from infection, 136 
Nux vomica, tincture of, in rickets, 
398 



Oat jelly, 211 
Oat-water, 210 
Oatmeal-water, 210 
Oil, cod-liver, 246 ^ 

olive, homogenized, in place of 
butter fat, 202 
in place of butter fat, 202 
Oily stool, 80 



478 



INDEX 



Ointment, bismuth, for dry, rough, 
not acutely inflamed eczema, 441 
boric, in seborrheic eczema, 442 
Olive oil, homogenized, in place of 
butter fat, 202 
in place of butter fat, 202 
Opium in fermentative diarrhea, 307 

in infectious diarrhea, 317 
Orange juice, 235, 437 

for artificially fed normal infant, 
243 
Ossification, zone of, 369 
Osteogenesis imperfecta, 395 
Osteomyelitis, scurvy and, differentia- 
tion, 43 1_ 
Osteoporosis, 374 
Overfeeding in breast feeding, 121 
Overheating of body in fermentative 
diarrhea, 297 



Pancreas, secretions of, 27 

Pancreatic digestion, 27 

Papular eczema, diffuse, 444 

Parathyroid glands in etiology of 
spasmophilia, 403 

Paregoric, 308 

Parenteral infections in fermentative 
diarrhea, 297 

Pasteurization of milk, 170 
what it accomplishes, 170 

Pateurized or boiled milk versus raw 
milk, 175 
versus boiled milk, 175 

Peptonization of milk, 212 

Percentage composition of feeding 
mixtures for infants three months 
old, 227 

Peristalsis of stomach, 24 

Peritonitis, tubercular, chronic in- 
testinal indigestion and, differentia- 
tion, 326 

Peroneal sign in spasmophilia, 407 

Phosphorus, absorption of, 63 
in cow's milk, 63 
in human milk, 63 
in rickets, 397 
in spasmophilia, 416 
lack of, as cause of rickets, 377, 378 

Physiologic importance of salts, 58 
loss of weight in newborn, 17 

Physiology of digestive tract, 22 

Poliomyelitis, scurvy and, differentia- 
tion, 431 

Potassium, absorption of, 62 
in cow's milk, 62 
in human milk, 62 

Potato and egg, 249 
as antiscorbutic food, 437 



Precipitated chalk in fermentative 

diarrhea, 307 
Pregnancy, breast feeding during, 114 
Premature infants, 340 
artificial food for, 353 
bath thermometer for, 350 
bed for, 348 

breast milk for, 351, 353 
Breck feeder for, 352 
feeding of, 351 
fluids for, 351 
general care, 346 
gown for, 349 
heat for, 347 

regulation, 349 
interval for feeding, 352 
oiling, 349 
physiology of, 342 
prognosis, 354 
room for, 348 
treatment, 346 
weight of, 345 
Prematurity, causes, 341 
definition of, 340 
incidence, 341 
Preservatives in milk, 156 
Prophylaxis of diarrheal diseases, 319 
Proprietary foods, 225 
Protein, 211 
absorption of, 37 
action of, in intestine, 37 
content of colostrum, 18 
digestion of, 37 
excessive putrefaction of, in protein 

stools, 87 
form of fermentative diarrhea, 309 
function of, 34 
in cow's milk, 148 
indigestion, acute, in bottle fed, 
263 
treatment, 264 
metabolism of, 34 
milk, 55, 140, 215 
dried, 218 
preparation of, 216 
in sugar fermentation, 301 
salt content of, 55 
needs, minimum, 35 
of cow's milk and of human milk, 

differences between, 177 
of human milk, 95 
groups of, 96 
of milk, effect of boiling on, 172 
period in development of modern 

artificial feeding, 125 
stools, 86 

with casein curds, 87 
with excessive putrefaction in, 87 
Protein-splitting bacteria, 151 



INDEX 



479 



Proteins, food, idiosyncrasy to, in 

eczema, 449 
Purgation in dysentery, 314 

in fermentative diarrhea, 300 
Putrefaction, 32 
of protein, excessive, in protein 

stools, 87 
types of bacteria which produce, 34 
Pyloric spasm, 456 
diagnosis, 457 
Fredet-Rammstedt operation in, 

461 
postoperative management in, 

462 
prognosis, 462 
Roentgen ray in, 460 
symptoms, 456 
treatment, 461 
stenosis, 117, 452 
diagnosis, 457 
etiology, 452 
Fredet-Rammstedt operation in, 

461 
occurrence, 452 
pathology, 453 
postoperative management in, 

462 
prognosis, 462^ 

Roentgen ray in diagnosis, 460 
symptoms, 453 

palpable tumor in, 454 
visible gastric peristalsis in, 454 
treatment, 461 

with slight obstruction, atropin 
in, 466 
feeding in, 464 
prognosis, 466 
stomach washing in, 465 
treatment, 463 

Red milk, 151 

Rennin, curdling of milk by, 211 
Rheumatism, scurvy and, differentia- 
tion, 430 
Ribs in rickets, 383 
Rickets, 41, 367 

bow-legs in, 386 

calcium in, 398 

cod-liver oil in, 397 

course, 400 

diagnosis, 393 

drugs in, 397 

epiphyses in, 387 

etiology, 372 

chemical and experimental find- 
ings in, 374 
clinical observations in, 373 

extremities in, 385 

feeding in, 396 



Rickets, fetal, 367 

general treatment, 399 

Harrison's groove in, 383 

iron in, 398 

knock-knee in, 386 

kyphosis in, 387, 399 

long bones in, 383 

occurrence, 367 

pathology, 369 

phosphorus in, 397 

prevention of deformity in, 399 

prognosis, 400 

prophylaxis in, 395 

ribs in, 383 

Roentgen-ray appearance of bones 
in, 387 

rosary in, 384 

scurvy associated with, 395 

shoes and braces in, 400 

spine in, 387 

stages of progress, 387 

sunlight, therapeutic effect in, 399 

symptoms, 379 

systemic changes in, 389 

teeth and jaws in, 382 

tincture of nux vomica in, 398 

treatment, 396 
Roentgen ray in diagnosis of pyloric 
spasm, 460 
of scurvy, 431 
Roentgen-ray appearance of bones in 

rickets, 387 
Rosary in rickets, 384 
Rotch, Biedert, and Meigs in develop- 
ment of modern artificial feeding, 125 
Rotch's work in development of 

modern artificial feeding, 129 



Saline injection, intraperitoneal, in 
fermentative diarrhea, 306 
subcutaneous, in fermentative 
diarrhea, 305^ 
Saliva, quantity of, in newborn, 22 
Salt content of cow's milk, 55, 148 
of human milk, 55, 97 
of protein milk, 55 
Salts and nitrogen retention, relation 
of sugar to, 46 
in cow's whey, 54 
mineral, metabolism of, 56 
of milk, effect of boiling on, 172 
physiologic importance of, 58 
Saprophytes, 28 

Saprophytic organisms in milk, classi- 
fication, 150 
Scrambled egg stool, 80 
Scratching, prevention of, in eczema, 
445 



48o 



INDEX 



Scurvy, 419 
active, 424 
acute nephritis and, differentiation, 

431 
antiscorbutic foods in, 436 
associated with rickets, 395 
capillary resistance test in, 429 
circulatory system in, 429 
diagnosis, 430 
digestive tract in, 429 
etiology, 420 
exophthalmos in, 428 
general symptoms, 425 
gums in, 427 

hemorrhage into skin in, 427 
latent, 423 
legs in, 426 
occurrence, 419 
osteomyelitis and, differentiation, 

431 
poliomyelitis and, differentiation, 

431 
prognosis, 436 
prophylaxis in, 433 
rheumatism and, differentiation, 

430 
signs, 423 
subacute, 423, 424 
symptoms, 423 

syphilitic epiphysitis and, differ- 
entiation, 430 
treatment, 436 
urine in, 427 
3c-ray in diagnosis, 431 
Scybala, 357 

Seborrheic eczema in infancy, 442 
Secretion of duodenum, 25 
of pancreas, 27 
of small intestine, 26 
of stomach, 24 
Sepsis in newborn, 21 
Shoe for rachitic children, 400 
Short method of calculating gravity 
cream and skimmed milk mixtures, 
190 
Skimmed milk and gravity cream mix- 
tures, 188 
long method of calculation, 

197 
principles of calculation, 

191 
short method of calcula- 
tion, 190 
dilutions in sugar fermentation, 
304 
with dried casein, 218^ 
with powdered casein in sugar 
fermentation, 302 
Skin, hemorrhage into, in scurvy, 427 



Skin of normal infant, 244 
test in idiosyncrasy to cow's milk, 
290 ^ 

Slimy and stringy milk, 151 
Small intestine, bacteriology of, 30 

secretion of, 26 
Soap stools, 40, 80, 127 

conditions in which formed, 41 
Soapsuds enema for constipation, 242 

for gas, 244 
Sodium, absorption of, 62 

and calcium, interrelationship of, in 

spasmophilia, 405 
bicarbonate, 212 
citrate, 212 
in cow's milk, 62 
in human milk, 62 
relation of, to spasmophilia, 405 
Soup, drimalt, extract, Borcherdt's, 
composition of, 207 
malt, extract, Borcherdt's, com- 
position of, 207 
dry, with wheat flour, com- 
position of, 208 
Keller's, 207 
Maltine malt, 206 
Sour milk, chemical changes in, 153 
Souring of boiled milk, 172 

of milk, 152 
Spasm, carpopedal, in spasmophilia, 
408 
treatment, 413 
pyloric, 456. See also Pyloric 
spasm. 
Spasmophilia, 41, 269, 402 
active symptoms, 408 
breast milk in, 414 
bronchial tetany in, 409 
calcium in, 415 

metabolism in etiology of, 404 
carpopedal spasm in, 408 

treatment, 413 
chloral in, 412 
Chvostek's sign in, 406 
cod-liver oil in, 416 
diagnosis of, 410 
drugs in, 415 
electric irritability in, 407 

reactions in, 416 
Erb's sign in, 407 
ether or chloroform in, 412 
etiology, 403 

facial phenomenon in, 406 
general condition of infant in, 410 

convulsions in, 409 ^ 
laryngismus stridulus in, 408 

treatment, 413 
morphin in, 413 
occurrence, 402 



INDEX 



481 



Spasmophilia, parathyroids in etiology 
of, 403 
phosphorus in, 416 
peroneal sign in, 407 
prognosis, 411^ 
relation of sodium to, 405 
signs of increased nerve irritability 

in, 406 
sodium and calcium interrelation- 
ship in, 405 
symptoms, 406 
tetany in, 408 

treatment of active manifestations 
in, 412 
of underlying condition, 414 
Trousseau's sign in, 407 
Spine in rickets, 387 
Spitting up, 243 
Spore-bearing bacteria in cow's milk, 

151 
Starch, 210 

absorption of, 56 

and fat indigestion, severe, com- 
bined, diet in, 335 
calculation of, 196 
in stools, 85 

fermented type, 85 

microscopic examination for, 

technic, 86 
unfermented type, 85 
indigestion, acute, in bottle fed, 264 
moderately severe, diet for baby 
of 2| years weighing 20 pounds, 
335 
omitting all starch in, 334 
injury, 135 
Starvation in dysentery, 315 

stool, 87 
Steapsin, 27 
Stenosis, pyloric, 117, 452. See also 

Pyloric stenosis. 
Stomach, 23 

anatomic capacity of, 23 
bacteriology of, 29 
digestion in, 24 
emptying time of, 24 
free hydrochloric acid in, 24 
motility of, 24 
peristalsis of, 24 
position of, 23 
secretions of, 24 
size of, 23 
Stools, color of, 27, 77 

fat in, of normal and abnormal 
bottle-fed babies, 44 
breast- and bottle-fed babies, 
44 
partition in, 42 
in infancy, 75 

31 



Stools in infancy, acid, 79 
alkaline, 79 
bile in, test for, 89 
color, 27, 77 
fat in, 42, 44, 80 
form and consistency of, 76 
general characteristics, 75 
hydrobilirubin in, 78 
macroscopic examination, 80 
microscopic examination, 81 
normal appearing, 81 
number per day, 75 
odor, 76 
oily, 80 
protein, S6 

with casein curds, 87 
with excessive putrefaction in, 
87 
reaction of, 78 
scrambled egg, 80 
soapy, 80 
starch in, 85 

fermented type, 85 
microscopic examination for, 86 
unfermented type, 85 
starvation, 87 
sugar in, 84 

test for gas bacillus in, 88 
of breat-fed baby, 110 
of diarrhea, 77 

of normal artificially fed infant, 242 
soap, 40,12 7 _ 

conditions in which formed, 41 
Streptococci in cow's milk, 153 
Subcutaneous saline injections in fer- 
mentative diarrhea, 305 
Succus entericus, 26 
Sucrose in infant feeding, 204 
Sugar, absorption of, 48 
assimilation limits of, 49 
diarrhea from, 43 
digestion of, 48 
fermentation, 50 
chemistry of, 50 

conditions which bring about, 52 
degrees of, 298 
feeding in, 301 

Finkelstein's treatment of, 140 
lactic acid milk in, 303 
protein milk in, 301 
purgation in, 300 
simple skimmed milk dilutions in, 

304 
skimmed milk with powdered 

casein in, 302 
treatment in mild cases, 300 
in severe cases, 300 
in intestine, normal action of, 49 
in stools, 84 



482 



INDEX 



Sugar indigestion, 260 

acute, in bottle fed, 259 

treatment, 261 
chronic, in bottle fed, 274 
treatment, 274 
malt, Borcherdt's, composition of, 

207 
of human milk, 95 
of milk, effect of boiling on, 172 
overfeeding with, in fermentative 

diarrhea, 296 
relation of, to gain in weight, 46 
to retention of nitrogen and salts, 
46 
substitutes for, in infant feeding, 204 
Sulphur, absorption of, 64 
in cow's milk, 64 
in human milk, 64 
Summer diarrhea, 293 
Sunlight, therapeutic effect of, in 

rickets, 399 
Supplemental feeding, 120 
Suppositories, 358 
Synthetic fat mixtures prepared to 

resemble fat of human milk, 203 
Syphilitic epiphysitis, scurvy and, 

differentiation, 430 ^ 
Syrup, corn, composition of, 209 



Tannalbin in infectious diarrhea, 317 
Taste of milk, effect of boiling on, 172 
Teeth and jaws in rickets, 382 

time of cutting, 245 
Temperature, body, of newborn, 19 
Tests, anaphylactic food, in eczema, 
449 
gas bacillus, technic of, 313 
Tetany, bronchial, in spasmophilia, 
409 
in spasmophilia, 408 
Tomato juice, 437 
Tonic for poor appetite, 366 
Tonsillitis, milker with, epidemics 

from, 154 
Top milk (cream) dilutions, 186 
Transitory fever of newborn, 20 
diagnosis, 21 
etiology, 21 
treatment, 22 
Triglycerid, 147 

Trousseau's sign In spasmophilia, 407 
Trypsin, 27 

Tubercular periotonitis, chronic in- 
testinal indigestion and, differentia- 
tion, 326 
Tuberculin test, 155 
Tuberculosis in cows, 154 
tuberculin test for, 155 



Tumor, palpable, as diagnostic sign in 
pyloric stenosis, 454 



Underfeeding in bottle fed, 256 
treatment, 257 

in breast-fed baby, 118 
Unfermented starch stool, 85 
Urine in scurvy, 427 

of artificially fed normal infant, 243 



Vegetables, green, 248 

in artificial feeding of normal 
infant, 243 
Vesicular eczema, 444 
Vitamins, 65 
action of, 66 

antiscorbutic, water-soluble C, 68 
importance of, in infant feeding, 67 
in milk, effect of boiling on, 172 
nature of, 66 
occurrence of, 66 
Volatile acids in butter fat, 147 
fatty acids, 51 

harmful changes from increased 
amounts of, 52 
Vomiting in infectious diarrhea, treat- 
ment, 318 
in newborn, 116 
cause, 117 



Warmth for marasmic baby, 283 
for premature infant, 347, 349 
Water, barley-, 210 

for artificially fed normal infant, 243 
in fermentative diarrhea, 304 
lime-, 212 

loss of, from body, 18 
oat-, 210 
Water-soluble B, 65, 66 
action of, 66 
C, 65, 66 
action of, 66 

antiscorbutic vitamin, 68 
Weaning, 110 

Weight, birth, regaining of, 19 
gain in, in newborn, 106 

in normal artificially fed infant, 

240 
relation of sugar to, 46 
loss of, in newborn, 17, 106 
amount, 18, 19 
duration, 18 
prevention of, 19 
of newborn, 17 
of older children, 241 
of premature infant, 345 



INDEX 



483 



Wet, oozing eczema, 439 

crude coal-tar for, 439, 440 
Wheat flour with dry malt soup 

extract, composition of, 208 
Whey, composition of, 213 

cow's, salts in, 54 

mixtures, 213 

calculation of, 195 

preparation of, 2 13 
Whitewash for intertriginous eczema, 

443 
Whole milk dilutions, 181 



Whole milk dilutions, way of using, 
183, 184 
with dried casein, 218 
Widerhofer in development of modern 

artificial feeding, 132 
Widerhofer's work in development of 
modern artificial feeding, 132 

Yeasts in milk, 152 

Zone of ossification, 369 



